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APPLICATION FOR PERMII� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES [PAYMENT ENVIRONMENTAL HEALTH DIVISION RECEIVED 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOC%TON, CA 95201 �[P 181990 SAt)jN COUNTY PERMIT ERPIRES 1 YEAR FROM DATE ISSUED FUOLICJOAEALTI-f SERVICES (Complete in Triplicate) ENVIRONMENTAL HEALTH DIVISION Application is hereby made to Sao Joaquin County for a permit to construct and/or install the work herein described.. This application is wade 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 17750 East Highway 4 City Stockton Lot Size/Acreage Annrn3r . l ar , Owner's Name SMS Br finers , INC Address 17750 East Highway 4 StnrktUnne 202 941 -ASIS Contractor H . L . Camp Dr1R . CQddress Rio Vista CA LicenseNo.507781 Phone707 374-23 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ s,(/,� HEfl C5(�� Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK RC�i � SEWER LINES n) � DISPOSAILfLD. - r OU�HOP. LINE //t V� FOUNDATION � t r AGRICULTURE WELL �l OTHER WELL f� PITS/SUMPS 1Sb' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS §0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing 5;" f l Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing)-55 15 • 5# ERW Specifications ST&r I'I P„bliic 13:Other In j e c t i6-Welta Depth of Grout Sea15500to su r$*gef Groat Premium Cm I I Irrigation 5 50.0 Approx. Depth 1 kEastern Surface Seal Installed by h a 11 ib ur t o n Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is N/A 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED N/A 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS N/A LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the perlormance of the work for which this permit is issued, I shall not e p y any person in such manner as to become subject to workman's compensation laws of California.”Contractor's hiring or subcontracting signature ca Ili the following: "I cer ify that;n the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa do of California." The It ant must call forlel required inspections. Complete drawing on reverse side. Signed L_ Title: ` f?E Date: I OxIt'v OR DEPRTMENT USE ONLYApplicationAccepted by '�'CI�r7�'Y' Date v AreaPit or Grout Inspection by Q!�Q Date Fina/I In/ss action by p Date Additional Comments: Wf _ isr{� / �` �•'/� _ Applicant - Return all tj c See to: San Joaquin County Publics Health Services, Environmental Health Permlt/Services 1601 E. Hazelton Ave.. P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DfATE9 9PERMIT NO. EH 13241REV,i/"S1 L • �I l� �_IC, '-( /�-013� FN't2e L v