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F APPLICATION h <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> @ey <br /> ENVIRONMENTAL HEALTH DIVISION Ag �±�i?!L . ;7,,, <br /> 445 N SAN JOAQUIN , PHONE ( 209 ) 468-3420 � J <br /> P O BOX 2009 , STOCKTON , CA 95201 � � tY� <br /> 'RI�t ,I p / <br /> PERMIT E%PIRES 1 YEAR FROM DATE ISSUED ` � rc,! , , . '1�(1,/ tss2 <br /> ; <br /> ( Complete in Triplicate ) <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. 549 and 1862 and the Rules and Regulations ofSari <br /> Joaquin County Public Health Services . <br /> Job Address 404 West Fremont City Stockton Lot Size/Acreage ti 1 arra <br /> Owner's Name Crystal Cream & Butter Address 1013 D Street Sacramento CAPhoneqlfi-444-7 nn <br /> o Rancho Cordova , CA <br /> contractor B & F Drilling Address 3663 OmeC Circle , # 8 License No. C57- 51942 >IPhone q16-631 - 11154 <br /> TYPE <br /> - - <br /> TYPE OF WELL/ PUMP : NEW WELL %) WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well. ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well Cq <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES St7 DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION ? Zd AGRICULTURE WELL OTHER WELL PITS / SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 (In Dia. of Well Casing 411 <br /> (-(Domestic/ Private fdcGravel Pack ❑ Tracy Type of Casing PVC Specifications <br /> I '1 Public ❑ Other 71 Delta Depth of Grout Seal 301 Type of Grout Cement- Rant linite <br /> I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by R F F Drilling <br /> Repair Work Done ❑ Type of Pump H , P. State Work Done _ w <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK : NEW INSTALLATION I I REPAIR /ADDITION. I I DESTRUCTION I I ( No septic system permitted if public sewer is <br /> available within 200 feet. ) <br /> Installation will some: Residence _ Commercial _ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK . ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. I] Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thisapplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 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, 1 shall not <br /> 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. / f-/�/' <br /> SignedX �i_ -k � Title: re. d . I & T 6PoA5Ctd Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date / 1f/ �`f [� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments <br /> Applicant - Return all copies to : San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin , P O Box 2009 , Stkn , CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED K H CEIVED SY AT PERMIT NO, <br /> EN 1 -24 IREV. 1 / xe) A9 �j'1 � jo- -�- �2 � � 9�. 92 _3(12 <br /> EH 114-1a (:J lllJ <br />