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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IL ' ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. .Jdb Address 4004 East Carpenter Road City Stockton Lot Size/Acreage Mike Catrina 318 Beecham Ct Phone 41.5 828 3911 Owner's Name Address Pleasonton, CA 9 588 Con'tfactor Clerk Well Address 2024 E- Charter Way License No. 371 �60 Phone 4627676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out-of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 2 ___,OTHER C3 , Monitoring W4c11 C7 F _m_ DISTANCE:TO NEAREST:,SEPTIC-.TANK_ SEWER LINES r ¢'" -_DISPOSAL"•FLD.- �W. ." PROP"LINE' � ^"` — - FOUNDATION AGRICULTURE WLL` E ,;:—""' OTHER WELL PITS/SUMPS T aW INTENDED USE TYPE OF WELL PROfiLEM,AREA-" ONSTRUCTION SPECIFICATIONS F 0 industrial ❑ Open Bottom t- a Manteca Dia. of Well Excavation Dia. of Weil Casing Domestic/Private Cl GrayelPack ❑ Trac Type ' Tracy yp of Casing Specifications I'I Public Other 171 Delta Depth of Grout Seal Type ofjGrout"F " i I Irri{latio`, _.Approx. Depth I # Eastern Surface Seal Installed by Repair Work pone W Type of Pump H.P. State Work Done 1140- 1Lk6"' 4fE�1ti1. ' Well Destruction ❑ Weil Diameter Sealing Material & Depth L t Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I l DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet;I ," Installation will serve: Residence T.. Commercial_ Other , Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ T e/Mf f Yp 9 Capacity No: Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: t, Well Foundation Property Line /} ell fill" «LEACHING LINE C)---No:.& length of Gees-1 t-1_1- ---A- �`� '�-----Total length/size----•---- -�•4 � ' FILTER BED ❑ Distance to�nearest: Weil Foundation Property Line t �f J SEEPAGE PITS { I I - Depth t Size _ Number FJ SUMPS""" _ Ll- DistanceAo_neafe tz': 7' Weld � Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and r rules and rag ations of the Sail Joaquin County Home owns err licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not. employ any pars n in such nner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature cartifies the folio "g:--+cy that in-the- ormanc •of•the work for which this permit is issued, I shall employ persons subject to workman's compertsa- tion taws o Ca ornia.", 1 The applica s call o II r it d i ct' ns. mplete drawing on.reverse side. l Signed X " T i t 5 r i;"jTitl." „......_ Date Ir FOR DEPARTMENT USE ONLY Application Accepted bye. 1 1" JJ Date Y .� Area Pit or Grout Inspection by Date Final Inspection by_r Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health i Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton. CA 95201FEE j I INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT'NO. i EM 13.21[REV.I/it 5)