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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 l 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 i Joaquin County Public Health Services. I Y Joh Address 2 7 0 5 2 E a s t i H i g h w a y 1 2 0 Cit E s c a l o n Lot Size/Acreage � Owner's Name Vernon Paul Raddack Address 27052 East Highway 120 Phone 209-838-1536 'l Contractor Eartht c , Ltd.tl, . Address 1830 Vernon St . #7 License No.408595 Phone 916-786-526 TYPE OF WELL/PUMP: !NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well 0 G e o t e c h. Boring PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Z Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK +4041 SEWER LINES +400' DISPOSAL FLD. - PROP. LINE +3001 FOUNDATION 1-2-00' AGRICULTURE WELL - OTHER WELL +400' PITS/SUMPS-____.. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C] Domestic/Private 0 Gravel'Pack ❑ Tracy Type of Casing Specifications I'l Public kl Other F1 Delta Depth of Grout Seat 40 to 5 0 1 Type of Grout c e m e n t ` I I Irrigation 40IApprox. Depth 11 Eastern Surface Seal Installed by li Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth T Depth t Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i LNo septic system permitted if public sewer is I 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 0 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 Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth ' Size Number [ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl l 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 signa'tu►e 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 i'-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 muoed for all a ired Opobtions. Complete drawing on reverse side. MSigned Title: �� J ce Date: �3 FOR PARTMENT USE ONLY Application Accepted by Date ArAa f Pit or Grout Inspection by Date Final Inspection b Date l Additional Comments: r 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 INE AMOUNT Dull AMOUNT REMITTED CK RECEIVED BY DATEEj PERMIT'NO. . EM 13-24 IREV.i I K sl �� 96 ^� S 'L 3 Y i EH 4426 1� �C, ✓