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r '- 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 EX-PI-RES_ 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 18470 S . PARADISE R D . City_TRACY Lot Size/Acreage Owner's Name ROBERT FRE ITAS Address 555 HOF,FMAN LN. BRENTWOOD PhoneU15 ) 634A500 contractor HENNINGS BROS. DRILLAddress 3525 PELANDALE AVE . License No. 290813 Phone 545-1185 TYPE OF WELL/PUMP: NEW WELL EX WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION I❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK 1,20 t SEWER LINES 120 ' DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing 611 H Domestic/Private M Gravel Pack CX Tracy Type of Casing PVC Specifications Il Public f-1 Ot ec Cl Delta Depth of Grout Seal Type of Grout-B-ENT_0 N T E I I Irrigation d� Approx. Depth I I Eastern Surface Seal Installed by __-HENN I N G S BRO_S__ _ — Repair Work Done 0 Type of Pump H,P. State Work OonaSl ah bY Wnprr_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.i n 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 Cl No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 ) Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 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 compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on rev rsa side. , Signed X HEN-N I N GS_ BROS. B y „_ Title; Date: JUNE 1 1 199 '�'�FQA&PAFITMLT USE ONLY Apphcati ccepted by Date_`C.f�Z-__ ` Area Pit Droutapaction bata Final Inspectionby Date Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., F 0 Box 2009,,Stockton, CA 95201 CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PJ RMiT'NO. a EH 13-24(REV,t/w si K r ��n .M __rZ_? r - � EH 13-26 V ` C I L