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ys. i i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX .2009, STOCKTON, CA 95201 �' PERMIT EXPIRES 1 .YEAR FROM DATE ISSUIM (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. ' Job Address 28400 CARTER RD . City E S C A L O N Lot Size/Acreage Owner's Name VILLA DEVELOPMENT Address P .O. B07( 477 Phone 886'5573 Contractor HENNI.NGSBROS.DRII:LINfidfess 3525 PELANDALE AVE . License No. 290813 Phone 545- 1185 TYPE OF WELL/PUMP: NEW WELL CA WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER IDMonitoring Well DISTANCE TO NEAREST:-SEPTIC TANK 100 r SEWER LINES 100 ' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 Dia, of Well Casing 6.rl rX Domestic/Private VXG►avel Pack L7 Tracy Type of Casing .Specifications I'I Public Ll Other n Delta Depth of Grout Seal 100 ' Type of Grout BENTONITE 1 I Irrigation c;;��6.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction © Well Diameter Sealing )Material & Depth Depth Filler'Naterial & Depth TYPE OF SEPTIC WORK: NEVA INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is _ available within 200 feet.) Installation williserve:..'R sidencei± 'Corrimerciai_ Other $� h Number of living units: Number of bedrooms Character:&soil toia,depfh;'of 3 feet: — Water table depth- SEPTIC TANK 0- Type/Mfg Capacity No, Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line l AEPAGE PITS I I Depth Size Number L N o N j f E SUMPS LI Distance to nearest: Well Foundation Property:line i j NG s 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 rules and regulations of the San Joaquin County Home owner or 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 F employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's Erring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on r�verse side, � r Signed X Title: Date: SEPT_ 3() . 1992 FOR DEPAR MEIT USE ONLY 'a Application Accepted by Date U �Z Area Pit or Grou Inspection by Data/a Final Inspection h Date�a S Additional Comments: -r l- r e- �" r .au�av Applicant ^ Return 0= copies to: San Joaquin County Public Health 4Ga7cS-�v2Ee Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 11 RECEIVED By DATE PERMIT'NO. f INFO fe '?CASH r EH 13.24IREV.t/M5) A/ /�] �� U (/ EH 1A-26 r 3,