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APPLICATION FOR PERMIT SAN JO•UIN COUNTY PUBLIC HEALTH SERRCES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ' P 0 BOR 2009, STOCKTON, CA 95201 i lj J f PERMIT EXPIRES 1 YEAR FROM DATE ISSUER (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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 535 Center Street City Stockton Lot Size/Acreage 3 acres Owner's Name Pacific Gas & Electric Address One California Street Phone (415) 972-1116 Attn: Yvonne Meeks San Francisco, CA 94106 Contractor Spectrum Exploration Address 2825 Myrtle St. , StoCktgrkenseNo. 512268 phone(209)465-871 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER (N 4 Monitoring . Wells DISTANCE TO NEAREST: SEPTIC TANK " 100 SEWER LINES DISPOSAL FLD. PROP.7L NErehol.es See Map FOUNDATION Z25 AGRICULTURE WELL OTHER WELL "10 r PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (MW-7, MW-8, MW-9, MW-10) Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 inches Dia. of Well Casing 4 inches 1) Domestic/Private CX Gravel Pack ❑ Tracy Type of Casing PVC Specifications Attached I'i Public 11 Other Il Delta Depth of Grout Seal 40 feet Type of Grout, Cement I I Irrigation r13'Approx. Depth I I Eastern Surface Seal Installed by t� Repair Work Done U Ty o1 Pump Nnne H.P. State Work Done _ l %V*#Destruction ❑Bo e %l meter 10 inches Sealing Material i Depth Cement aroUt to 2 5 f e t t Borehole Depth 25 feet Filler Material s Depth (16117118,&2 ) ` TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) r 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 ❑ Type/Mfg Capacity No. Compartments 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 I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby cenify 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 must call for a,N�rfi9uired instions. Complete drawing on reverse side. Signed X 5�,�,Q F_n r n IN Title: Date: FOR DEPAR MEN U&0'NCLy Application Accepted by _ fL `g `��l �,�,LLn��.� /: Data `I( �� A!eea Pit or Grout Inspection by lY_'SatslscJ=l(LsA-6e1� x.17/Y - Final Inspection by wt .�.+YLL1. - Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services G/ 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 2 r•s 5,� IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED Sy DATE PERMITNO. • EMfY24(REV.11951 .0D Qy, 0 b yo _� 1q1-3C91 1 EN ibis