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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 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sen 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 3601 Undine Rd. City Stockton Lot Size/Acreage 135 acres Owner's Name I v i n Cerr i Address 2795 W Undine Rd. , STockton Phone465-8641 contractorNe_nn_ings Bros. Address 3525 Pelandle, Mod. License No. 290B13 Phone TYPE OF WELL/PUMP: NEW WELL [)( WELL REPLACEMENT ❑ DESTRUCTIONOut of Service Well 0 PUMP INSTALLATION C1SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK 13f)LIP� SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE_CIFICATIQNS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing 61, EX Domestic/Private IRGravel Pack Type of Casing PVB Specifications 160 I•) Public C Other 4.BeF� Depth of Grout Seal Type of Grout._BP_n'.0nitP_ I I Irrigation a.lpp(ox. Depth I ) Eastern Surface Seal Installed bydid 1 1 Qr Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material L Depth ,Depth- Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l 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 Character sol 'soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 15" X 1 F, SEEPAGE PITS 11 Depth Size Number r, _�•r.yLi t E3 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 1 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 workmen'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 revs side. Signed x Title: Date: 6-10-91 R DEPARTM T USE ONLY a/7 Application Accepted by Date / Area Pit or E9211pection by L4 Date Z4 Final Inspection by Date_ Additional Comments: Applicant - Return copies to: San Joaquin Co y Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO. AMOUNT DUE AMOUNT REMITTED CK f- CASH RECEIVED BY DATE PERMIT'NO. • EH 13.24(REV,i t H 5) EK 14-26 mie Ll 13"73 0-71