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J, 4 APPLICATION F SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 made in compliance with San Joaquin County Ordinance No. 549 and .1862 and the Aules and Regulations of San Joaquin County Public Health Services. Job Address 2825 W. Washington St . City Stockton Lot Size/Acreage r Owner's Name Riverside Cement CO Address 660 N. Diamond Bar Phone (909) 861-21 4 a 1 ornla Partnership Diamond Bar, CA 91765 Kcontfactof Self Address License No. NSA _ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC ENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTE REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A CULTU WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom Q Manteca . of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack C7 Tracy Type Casing_ Specifications FI Public C] Other ❑ Delta Depth of t Seal Type of Grout I I Irrigation _Approx. Depth I I East Surface Saul Inst d by Repair Work Done ❑ Type of Pump H. P. _ to Work Done 1 Well Destruction 0 Well Diameter suing Material & Depth Depth Filler Material & Depth 1 PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONDESTRUCTION I I INo septic system permitted if public sewer is ✓ available within 200 feet.} 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/Mfglk� Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: X Well r I Foundation t3 �' Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED Distance to nearest: �CN/eil foundation h x Property Line 01 SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS a P 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 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 worts for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must c4l for all require in�s9pet inns. Com/plate drawing on reverse side. Signed Title: ✓ Date: S,?;kEPARTMENT USE ONLY �n 2 Application Accepted by Date ✓ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: f e 1 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT.REMITTED CK 11 RECEIVED BY DATE PERMIT'NO. INFO / CASH . EK 13-2401 EV.IIR61 L l Vr lc��/r/ �� (/3 J^f.•� ,-! EK 14.21 t