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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 PEMIT 1 YEAR'FROM DATE ISSUED (Complete in Triplicate) Application to 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 17255 Trethway City LockefordLot Size/Acreage 2 aCreS Owner's Name Allan Cohn Address 17256 T Phone 333-7411 • 1 _ s .ContractorT Hennings Bros. Address -3525 Pelandale, Mod_ License No. 29 B13 _Phone545-1185 TYPE OF WELL/PUMP': NEW WELL ❑ WELL REPLACEMENT XX DESTRUCTION [))Put of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1 • OTHER ❑ Monitoring well L7 'DISTANCE TO NEAREST: SEPTIC TANK 1001 SEWER LINES DISPOSAL FLD.10.0' PROP. LINE 1 FOUNDATION AGRICULTURE WELL _ OTHER WELL t PITS/SUMPS e i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !I E Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing rr IX Domestic/Private XI Gravel Pack ❑ Tracy Type of Casing Specifications -----1bn I'.l Public f:7 Other fl Delta Depth of Grout Seal I Type of Grout-Renton ltp 11 Irrigation —.Approx. Depth ( I Eastern Surface Seal Installed b Repair Work Done LJ Type of Pump H.P. State Work Done_. Well Destruction 2 C Well Diameter 1011 Sealing Material & Depth Depth 901 Filler Material & Depth Bentonil:elhole -�1110- TYPE OF SEPTIC WORK:- NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer'is available within 200 feet.) Installation will sgr've:u:Residence Commercial_ Other i f4 ' ; Number of living units: Number of bedrooms = Character ofsoil,to a depth of,3 feet: Wateritable depth "K SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmants PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest"l,' Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line fill SEEPAGE PITS I I Depth Size Number . , SUMPS C3 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that,) have prepared this application and that the work will be dome in accordance with San_ Joaquin county,-ordinances, state laws, and rules and regulatioAs 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 reverse si , r a . g Henn i n Date: Signed k_-- CJS Bros„ Title. 8-24-92 rIF DEP MENT USE ONLY 4� q Application Accepted by Date c� if Z Area 4 Pit or ro Inspection by 'f-zJ y %t�4 ae,4. Date �/" Final Inspection by_.� // >/ _ Date Additionaf 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 r _ .,INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO ' EH 13.21[REV.iinS) CR f C} r G.7 Zr