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O 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 2ERMI1 EXPIRES I 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 Coun_k 0dn ee N 549 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. _3 g oDo r Fap N 2657 2015 .5 miles south of south end of B-ird Roadcity San Joaquin Lot Size/Acreage 186 A. Job Address County Owner's Name Robert Bocletti Address 3559 Shiloh _Rd. Modesto 953-U Phone 832-2205 95201 i Contractor' Granite Cons tructi onAddress P.0•BOX 151, StOCkt4lL__ License No. SS _Phone ' TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CXnit i Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 3000' SEWER LINES DISPOSAL FLD. PROP FOUNDATION AGRICULTURE WELL _L 000 y OTHER WELL_ 3000 r_- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 6 Dia. of Well Casing [I Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t I'] Public [-I Other n Delta ` Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by iRepair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth wet = bentani i P _ O 4 Depth 160- '.t'DO r Filler Material & Depth dry = native materid] G TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I ) INo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 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 i ❑ No. & 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 Propeity Line DISPOSAL PONDS ❑ f I hereby certify that f 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."Contractors 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 compensa- tiZ;:n laws of C ' rnia." The applica st call for all re u'ed i s ctions, omplete drawing on reverse side. Signed X Title: Stockton Branch Manager gate; Ari I- '26 1990 - Jades H. Essi < ODEPARTMENT USE ONLY I ~ � y l Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Q Date 6 �� 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 H RECEIVED BY DATE PERMIT'NO, i • EH17.21 IREV. /x 51 EH f i