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T APPLICATION FOR PERMIT <br /> SAN TOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIMTAL HEALTH DIVISION <br /> .� <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O- BOX 2009, STOCKTON, CA 95201 <br /> pER_![_I_ T Ki PIRTS 1_YTAR FROM_ DAT ,�$11� <br /> (Complete inTriplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin county Ordinance No. 51+9 and 1662 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> Job Address <br /> 19527 $Oilth.MCHen City ESCalon• Lot Size/Acreage 40 <br /> Owner's Name <br /> Hogan Mf ., Inc. Address 19527 South McHenryPhone 209)538-7323 , <br /> Contractor <br /> Don Lambert & Sons Address 121 F St. Waterford License'No. A561566 Phone(209)874-216 <br /> � <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION §7 Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl industrial ❑ Open Bottom © Manteca Dia- of Weil Excavation Dia. of Well Casing <br /> C-1 Domesticl Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications-- <br /> i'I Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I l Irrigation ^.Approx, Depth ' I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ] Well Diameter 8rr Sealing Material i Depth Oi1C et ll <br /> Depth 500r Filler Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: N A Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines N A Total len gthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth N Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> l 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 <br /> f rules and regulations of the San Joaquin county <br /> 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 <br /> I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> Theapplicant Vr require pe Complete drawing on reverse side. <br /> signed x Title: Controller Date: 09/24/90 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date fV. v Area <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permlt/Services <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CATHRECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH 13.711REV.It K 51 <br />