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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)458-3420 P O BOX 2009, STOCKTON, CA 95201 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' (Complete in_'[ pbum epwicnaTHMMUS Application is hereby made to San Joaquin County for a permit to constj� �hereinSlescribed. This application is made in compliance with San Joaquin County Ordinance No. 54 t�1 ?� d�thenr)�f� "tions of San Joaquin County Public Health Services. SvP�j 11 r�`+jj�1��r�� I Job Address _ 141_El Dorado _..- City Stockton Lot Size/Acreage C.M. Weber-Enterprises Ca. 95818 Owner's Name Gurtrude Weber Add res� 3757 Col l ci e Ave Sacramento Phone 2L61443-1561 J V+ e- C1, 4 56 7$ Contractor PC Exploration -Address 1780 Vernon Sto ,#FLitenseNo. 265556 Phone 916/783-97D TYPE OF WELL/PUMP: NEW WELL O_ WELL REPLACEMENT CJ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION E7 SYSTEM REPAIR C] OTHER �K Monitoring Well X1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ZO -feet DISPOSAL FLD. PROP. LINE 10 feet FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial D Open Bottom D Manteca Dia. of Well Excavation_-1.0-inch Dia. of Well Casing C7 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing :'$C.hedUl.e _40 PVC Specifications I'1 Public iXOthefA MW t s F1 Delta Depth of Grout Seal 1:O t0 '30 feet Type of Grout_. OeMe:,O,l I I i Irrigation 40 t0RUpprox. Depth I i Eastern Surface Seal Installed by i Repair Work Done D Type of Pump N/8H.P. NIA State Work Done_ Weil Destruction ❑ Well Diameter NIA Sealing Material & Depth Depth Filler Material & Depth f TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION [ I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_..` Commercial_ Other W. Number of living units: Number of bedrooms i y Character of soil to a depth of 3 feet: SEPTIC TANK. Water table depth ` © Type/Mfg Capacity No. Compartments t� PKG. TREATMENT PLT. ❑ Method of Disposal } Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 - Depth Size Number � 1 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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 i 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 1 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 compensa- tion taws of California." The applicant mu c I required inspections. Complete drawing on reverse side. p r Signed U 6 -a Title: L.OW.SV I U- n � ate: ) 2.4 !/ �0 4 _ F DEP NT USE ONLY Application Accepted by Date ' t Ar ' Pit or Grout Inspection by Date ' incl Inspection by Date �G Additional Comments: f Applicant - Return all copies to: San Joaquin County Public Health Services;.Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Bax 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CH KSRECEIVED BY DATE PERMIT'NO. I' 11 INFO CA �9 �f EN A-21 PREY. /w 5l EM A-25 [J / (Yrs//6+ ( 7 (�(•�/