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I.' r APPLICATION FOR PERMIT E' 7� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH, DIVISION . s..=. .. E 1601 E. HAZELTON AVE.-, PHONE (209)468--3420 a P O BOX 2009, STOCKTON, CA 95201 ' REMIT EXPIRES 1 YEAR FROM DATE1.59iUM) 16 (Complete in Triplicate) ��` � Application is hereby made to San Joaquin County for a permit to construct and/or install thee" t described. This application is made in compliance with San Joaquin County Ordinance No. 5h9 and 1862 and the AulpE r� tA�of San Joaquin County Public Health Services. �,S'ERVIi Job Address 3686 Country Club Blvd. , .city Stockton Lot Size/Acreage Approx. 1 acre 'I Owner's Name 0r• Karabal d Address 3686 Country Club Blvd. Stockton -Phone (209) 466-7755 l contractor Excel tech Address 41574 Christy St; Fre OTCehse No-464a2*- Phone(415), 659-0404 TYPE OF WELL/PUMP: NEW WELL ❑ WELLREPLACEMENT' 17) DESTRUCTION ❑ Out of Service Well C1 ' PUMP INSTALI-A'"r." r1 SYSTEM'REPAIR C1 P&/yaQTFEER 6� Monitoring well �} .. ,.- "-'-'[ate STANCE TO NEAREST: SEPTIC TANK-- -" * i SEWER LINES, - 50 f. DISPOSAL FLD. PROP. LINE FOUNDATION —20—ft--_ AGRI ULTURE WELL. OTHER WELL '" P1T5/SLOPS°"' �• INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ". F)"industrial ❑ Open Bottom ❑ Manteca . " ti Dia. of Well Excavation n• Dia. of Well Casing Domestic/Private U Gravel Peck ❑ Tracy" - Type of Casing Specifications 1'I Public (XOtherri n Delta Depth of Grout Seal r^12 ft. Type of Grout Cement sl ur I I Irrigation iz.kpyFox _%PIh 11 Eastern Surface Seal Installed by ' Repair Work Done U Type of Pump # H.P. .+ StataVNork Done_ ( 1"� Well Destruction O Well Diameter 7 7 n. Sealing Material & Depth Qf at!wr sail boring Depth _12 ft. Filler Material & Depth TYPE OF SEPTIC WORK: NEW:INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septie.system permitted if public sewer is r available within 200 feet.► r Installation v'CIF e: Rasidence_ Commercial_ Other Number of living units: umber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TypelMfg. r Capacity No:,Compartments PKG. TREATMENT PLT. ❑ `; Method of Disposal Distance'to nearest: Well Fou Property Line LEACHING LINE ; y C1 No. & Length of lines Total la thJ�s�ize,_ FILTER BED C1_ Distance to nearest: Well Foundation Propertyrre i SEEPAGE PITS' 11 Depth Size Number _SUMPS •� + 1_I to nearest:" "s Property- Distance Well---- � -Foundauon� — 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, statelaws, and i 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 employ any person in such rnanner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature i 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 applicantm t c all re fired inspections. Complete drawing on reverse side. 4 n + Signed Title: Date: I { /7 FOR 0EIPAATMENV6S9 ONLY Application Accepted by. Data v Jv Area Pit or Grout Inspection by Date Final Inspection by Date JJ �C Additional Comments: `* _ Applicant -• Return all copies to: "San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. °� JD1 q� s EH H . 24 IREV. 1"51 A 4- fH.4-Zs i