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• APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388, STOCKTON,CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 375- West Hazelton Road City Stockton Lot Size/Acreage Owner's Name Sierra Lumber- Address Same as above Phone Contractor Great Sierra Explorat]iefiess 7460 Redwood Blvd. , Novi QIse No. 610487 Phone 415/898-118 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X . well ❑ Soil Boxing DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. ONE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dis. of Well Casing ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing_ Specifications I'I Public 1-1 Other n Delia Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth_ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (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 of soil to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founcahon Property Line SEEPAGE PITS 1.1 Depth Size Number 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 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 workman's compensation laws of California." Contractor's hiring or subcontracting 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 comport". tion laws of California." The appli t must call for NI required inspections. Complete drawing on reverse side. ** See attached Site Map** Signed C 'Ie: President 6/ 94 FOR DEPARTMENT USE ONLY Application Accepted by DatL f Ar Pit or Grout Inspection by Date Final Inspection by '" Date? 1 o 5 1 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health PermiVServices 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 FEE m a INFO AMOUNT DUE AMOUNT REMITTED CASH I RECEIVED By DATE PERMIT'NO`.' • EM l3 24 II1EV.1/n 51 at +� U 0�f/ y EH u.M