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�1 APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMEN Y ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 RECEIVED (209) 468-3447 MAR 11 1991 „REMIT E%PIRES 1 UAR_PROM DATE ISSUED- SAN JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVOO Application is hereby made,to San Joaquin County for a permit to construct end/or inatall the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 5400 Pacific Avenue City Stockton Lot size/Acreage Owner's Name Montgomery Ward Address 39201 Fremont Blvd. , Fremont Phone 1016 Katella east CA 94538 Contractor West Hazmat Drilling Address Anaheim, CA 92805 License No. 554979 Phone 714-939-685 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERA' Monitoring Well i7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL L I A' PITS/SUMPS .� INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing U Domestic/Private Cl Gravel Soil L7 Tracy Type of Casing Specifications Public 10 to 1 ratio Other ❑ Delta Depth of Grout Seal T pe of Grout 30 bo Ing o cement to water r! M Irfioalion Approx.�epg 0 Eastern Surface Soul Installed by Repair Work Done U Type of Pump N.P. State Work Done with 3 to 5% bentonite Walt Destruction ❑ Well Diameter Sealing Material i Depth R added. Depth Filler Material i Depth r TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIR/ADDITION 0 OESTRUCTION 0 INo septic system permitted if public sewer is ,X. available within 200 feet.! Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms 13 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 7) PKG. TREATMENT PLT. Ci Method of Disposal �y Distance to nearest; Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size , FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Lina 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 employ any person in such manner as to become subject to workman's compensation laws of Csl'ifornia." 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, I shall employ persons subject to workman's compensa. tion laws of California." The applicant mist call for all required inspections. Complete drawing on rover" �side. Signed Title: Data: 2 Z&Lit r FO PARTMENT USE ONLY 7 ! Application Accepted by Date J I Area 2 Pit or Grout Inspection by Date Final Inspection by Date Additional Commerillts: _ Applicant - Retu m all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 995 H SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C(�AS,.rH� RECCEEI/ryVJEDDBY 1DDATEE -PERMIT,NO. EH'�42;trIEV.i,w51 •O� i i