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APPLICATION SAN JO QUIN COUNTY PUBLIC HEALTH SIF-AVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 msde 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 1905 McHenry Avenue City.F.cr��1 nLot Size/Acreage �z Owner's Name Escalon Packers Address same Phone 8387-34 1 - Sacramento Contractor West Hazmat Address 3233 Fitzgerald License No. 554979 Phone9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑soil b or i91V ER M Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK tl-1A SEWER LINES 301 DISPOSAL FLO.___a/a PROP. LINE )n I FOUNDATION 7(1 ' AGRICULTURE WELL _Il,L OTHER WELL----A. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial O Open Bottom O Manteca Dia. of Well Excavation R " Dia. of Well Casing Fl Domestic/Private O Gravel Pack 0 Tracy Type of Casing n/a Specifications y I'1 Public C1 Other n Delta Depth of Grout Seal n ' Type of Grout n, a-I- cpw n I I Irrigationa Approx. Depth II Eastern Surface Seal Installed by .i Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material b Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) _. Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments T PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line lI LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 cenifies 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 Fust c r for all fired inspections. Complete drawing on reverse side. / Signed X Title: ��>✓ d �/,9��T Date: 6 2� /Z OR D PARTMENT USE ONLY Application Accepted by - Date Area Pit or Grout Inspection by � Final Inspection by � Dato SAd�d{i�Q>� A �hh QNA0 T"i1EATPTs o: `SNJoaquin County Public Health Services / q Environmental Health Permit/Services �v SPECIAL PEl`'1v11T5 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO (G��_,' 11�1{�t- 1 x-11�• ��'1f /�]1 EN 13.24(REV.1/"5) 7�1`-1 •(,! �/ a b C.�'�! f� i _ 1 / ' f EH 14.20 lJ 1