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• APPLICATION FOR PERMIT 40 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 fi. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCBTON, CA 95201 � � I IT E%PIRES 1 YfiAR FROM DATE TSSULM Application is hereby (COmPlete In Triplicate) application is made In c to San Joaquin County for a permit to construct and/or install Joaquin County Public" h San Joaquin County Ordinance No. 549 and 11;62 and the work herein described. _This Job Address South east corner of Commerce & Lafayett the Rules and Regulations of San �hy SIOA Lot Size/Acreage -- Owner': Name Pacific Gas & Electric _ Attn: Yvonne Mees Address One California Street Conlraclor Spectrum Exploration San Francisco, CA 94106 Phone (415)972-1116 TYPE OF --'—�Address 2825 Myrtle St, , Stoic eklense No. 512268 (209)465-871 NEW WELL ❑ WELL REPLACEMENT ❑ Pnone DISTANCE TON PUMP INSTALLATION ❑ DESTRUCTION ❑ Out of Service Well ❑ NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ See Ma SEWER LINES L 50 r OTHER a Monitoring Well FOUNDATION DISPOSAL FLO. 1 Borehole ❑ INTENDED USE AGRICULTURE WELL PROP. LINE �_ (B-22) TYPETYPE—�EL� PROBLEM AREA OTHER WELL PITS/SUMPS _ C7 Intlustria—� ❑ Own Bottom CONSTRUCTION SPECIFICATIONS Noe w/ BOre#9 g UMed N Domestic/Private ❑ Manteca Dia. of Well Excavation Be j SV lofas tt ❑ Gravel Pack ❑ Tracy Dia. of Well Casing or AD I'I Public Cl Other Type of Casing 1 1 Irrigation fl Delta - Depth of Grout Seal Specifications Repair Work Done —Approx. Depth I I Eastern ---�_ Type of Grout—� ❑ Type of Pump Surface Soul Installed by �WetPOestruction ❑ �� H.P. \r WINFDiameter 10 inches Sealing Material i State Work pone_ 1, Borehole Depth 25 fe_ e— nth Cement r r_ met TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPA RlADOI OFiller tN lid 1 i Depth U DESTRUCTION I I (No septicsystempermitted if public sewer is r Installation will serve; Residence Commercial_ Other available within 200 feet.) __ --�_ Number of living units:Character Of of Soil to a depth of 3 feet: o/bedrooms �(djT SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLL ❑ Capacity_ No. Compartments Distance to nearest: Well Method of Disposal Foundation Pro rt LEACHING LINEe Y Line Cl❑ No. & Length of lines FILTER BED ❑ Distance to nearest: Total length/size Well Foundation SEEPAGE PITS Property Line I I Depth —Size SUMPS LI Distance to nearest: Number DISPOSAL PONDS ❑ Well Foundation Property Line I hereby certify that 1 have prepared this aCounttron and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San red thin 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the foSowirp: "1 certifythat in the Performance of the work for which this permit is issued, I shall em to P tion laws of California." p y persons subject to workman's compensa The apo"csnr must cam row as renis;red ions. Complete drawing on reverse sid Signed X� — ' —�-- Title: / N/ Oats: FOR DEPAA 7 USE dN� Application Accepted�Jby�0 V�JFfi'\ Ct LiA-1 {� •1 _ Pit or Grout InspeclfS6yy�y� G- sf Date ( ��--� II/////"```"'''... �z Area Date Final Inspection by Additional Commence: Date Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. LzeltOn Av ., P 0 Box 2009, Stockton, CA 95201 lmagtg;� /• 5Y REMITTED CK t RECEIVED aV CASH !--�-5911-30) I1Q5 IREV.irxm �/ PERMR'NO. ,,.ie C I�