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APPLICATION SAN J6AQUIN COUNTY PUBLIC HEALTH 8--,A' VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1905 McHenry Avenue City ESfia I on Lot Size/Acreage Owner's Name Escalon Packers Address same Phone PAR7341 - Sacramento Contractor West Hazmat Address 3233 Fitzgerald License No. 554979 Phony TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑soil boriAT,JriER N Monitoring Well O n ;ayy DISTANCE TO NEAREST: SEPTIC TANK __T a_ SEWER LINES 'In r DISPOSAL FLO._ /a PROP. LINE 1)QQ r FOUNDATION fin ' AGRICULTURE WELL _n4-a- OTHER WELL 34 ' PITS/SUMPS _nJa INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation R" Dia. of Well Casing F.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- n/a Specifications y (1 Public (-1 Other n Delta Depth of Grout Seal 11 r Type of Grout I I Irrigation304Approx. Depth 11 Eastern Surface Seal Installed by _ Repair Work Done U Typo of Pump H.P. State Work Done _ r, Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 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 Lino DISPOSAL PONDS O 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 sub-contracting signature certifies the following: "I cortify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant fytusL c for all r fired inspections. Complete drawing on reverse side. Signed X jr+/ Title: �� Date: 6 ti OR D PARTMENT USE ONLY C�/ Application Accepted by '"�' - Date L r 9 L' Area Pit or Grout Inspection by Final Inspection by Data SMJC AQWN ApWWNAUNTA16REWp s- o: '§QNJoaquin County Public Health Services �1 Environmental Health Permit/Services SPECIAL PEI�lvi 15 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO EH 14.26 EN 13.24(REV.1/"5) 1