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APPLICATION FOR PERMIT n j? SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE U I ti ENVIRONMENTAL HEALTH DIVISION MAY 1 71990 PAYMENT 1601 E. HAZELTON AVE. , PHONE (209)46$-3 E� P 0 BOR 2009, STOCKTON, CA 95201 RECEIVEDMAY 2 2 E EZP RES I .YEAR FROM DAT N OA U {� !N COUNTY (Complete in Triplicate) p 9 *tttrrWWDESo San Joaquin County for a permit to construct and/or install the work herein described. This �IM DWOU ice with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San c Health Services. Amb , I IX Job Address _C►^ .�Sr� P�2+I 7�a,n�-l-C-O- City Tr cy Lot Size/Acreage D(. Owner's Name Standard Parifir Address Phone (415) 847-2700 Pleasanton 94566 Contf actor_ SR Pltmn and Well Coddtess License N4 7-068648 Ph4r408 727-3396 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION. Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL` PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREAT CONSTRUCTION SPECIFICATIONS n Industrial 1:1 Open Bottom C7 Manteca Dia. of Well Excavation Dia. of Well Casing f7 Domestic/Private ❑ Gravel Pack C3 Tracy Type of Casing Specifications I'1 Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout 1 I Irrigation ..._...Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done i❑ Type of Pump H.P. tate Worko e / Well Destruction 0 Well Diameter Z Sealing Material & Depth �/1?tl 0 ; Filler Material & Depth Depth Ila F SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION 1 1 DESTRUCTION I I INo septic system permitted if public sewer ' available within 200 feet.] Installation wills Residence_ Commercial_- Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: r table depth SEPTIC TANK. C3 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well anion Property Line LEACHING LINE 0 No. & Length of lines length/size FILTER BED CI Distance to t: Well Foundation Pr Line t� SEEPAGE PITS Depth Size Number SUMPS Ll Distance to nearest: Well Foundation— Property Line DI AL PONDS CI �.r 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 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 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 m t call for all required inspect'ons. Complete drawing on reverse side. Signed X r Title: Exec. Vice President Date: 5-18-90 FOR DEPARTMENT USE ONLY 'f Application Accepted by DataArea Pit or Grout Inspection by Date Final Inspection by °c" Date �/�' foo { `�-sack Ce. ,a--t YG'nc.t- 3"`� ce Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO �^ EH 13-24 1M.it K 51 16010 C-0 EH 34•25 �t