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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 pRRY7T EXP RES 1 YEAR FROM DATS�SSUED (Complete in Triplicate) i 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 2796 W. Undine Rd. City- S OCkt)1) Lot Size/Acreage I Owners Name Ivin Cerri & Sons Address 2796 W kton - Phone i Contractor Hennings Bros. Address 3525 PeIandale, M d License No. 1QB 3 Phone - TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT K-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 6d t SEWER LINES DISPOSAL FLD. 10a�j PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 200 I PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ri L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 160 fX Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing _— Specifications -- - -- CI Public CZ Other 1 De Depth of Grout Seal — Type of Grout I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter sealing Material & Depth Depth Filler Material & Depth ^) F11, , TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION t I INosbptiw thin system emitted if'public'sewer is ava4 J0 Installation will server-Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil toes 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 ® No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line en ^ Number SEEPAGE PITS i I Depth Size u i i,£ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E I hereby canify 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 canities the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections_. Complete drawing on re rse side Signed Hinnirigy Rrnc Title: Date: DEPART M 7 NT USE ONLY �' Application Accepted by� Date Area Pit6�1 spection by atp�/ inal p� �� ® Dat Additional Comments: I `/ n Applicant - Return all cop es to: San Joaquin County Public Health ` �'�c �f1 Tea S r 2 Services, Environmental Health Permit/Servicee l ( L 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 'Z PEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO, INFO . EH r3-24(Rev.r/85)�R• � � .�+�� - m� ��a EH 94.26 C�