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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ` 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address / /d/ r Al ity� eT �TON Lot Size/Acreage Owner's Name SAN TOMO Address 11292 N . ALPINE S T O C K T O N Phone 948-4022 95356 Contractor HENNTN-,S BROS_ I)RTI_I _Address 3525 PFI ANDAI F, MOn License No. 290813 Phone TYPE OF WELL/PUMP: NEW WELL XX WELL REPLACEMENT O DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 400 t + SEWER LINES 400 t + DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 16 11 X 1/4 11 Cl Domestic/Private EV Gravel Pack O Tracy Type of Casing STEEL Specifications I'1 Public 1-1 Other Fl Delta Depth of Grout Seal 5 0 t Type of Grout CEMENT \ X Klrrigation Approx. Depth I I Eastern Surface Seal Installed by H E N N I N G S BROS. DRILLING Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material 0 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will some: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of sok to a depth of 3 fest: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity------ No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring 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 compenss- tion laws of Cakfornis." The applicant must call for MI required inspections. Complete draw g o reverse side. Signed p Titley _ Date: APR. 26 , 19 9 3 r FORIDEPART ENT USE ONLY Application Accepted by '�'��'"ice^ *- `a asl� Dots _�' e A ti Area r\= Pit or Inspection by iT�-"Date ILa/-'23 Final Inspection by e,�,2 Date 2-2k:2 3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE A U/N�T REMITTED 14V7 JACK ECEIVED 8Y TE PERMIT'N0. EH 13.24INEV.rinse , �� qq- flc,?2EM 11.2m /