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