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APPLICATION FOR PERMIT SAN •QUIN COUNTY PUBLIC HEALTH S VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby merle 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. City Stockton I.ot size/Acreage 3 acres Job Address 535 Center Street Owner's Name PG&E Address P.O. Box 7640 S F ra 9412Q Phone - 1150 W. Trenton Ave. _ 0 Contractor H-F Drilling Address Orange CA q icense No. 505990 Phone TYPE OF WELL/PUMP: NEW WELL ® WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Yell Aa DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 12 inches Dia. of Well Casing 4 & 5" Industrial O Open Bottom ❑ Manteca Die. of Well Eaca PtVC Specilicatbns CI Domestic/Private Q Gravel Pack ❑ Tracy Type of Casing_ Type of GroutCement I'I Public 17 Other n Delta Depth of Groan Seal H-F Drilling I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by H p State Work Done _ Repair Work Done ❑ Type of Pump Sealing Material i Depth Dep Well Destruction ❑ Diameter Filler Material a Depth Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION DESTRUCTION 1 I IN.ava"Pull system lable shin 200 teattled it public sewer is Installation will serve: Residence_ Commercial.— Other Number of living its: _ Number of bedrooms Water table depth Character of so a to• th of 3 lest: No. Compartments SEPTIC TANK O /Mfg acity PKG. TREATMENT PLT. O Method of Disposal Distance to near Foundation Property Lina LEACHING LINE ❑ No. 8 L of lines Total length/size FILTER BED ❑ ones to nearest: Well ation Property Lina SEEPAGE PITS I I Depth Size mbar SUMPS LI Distance to rarest: Well Foundation Property Line 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 Canty 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 subcontracting 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 Colifornla." The aDdi t must ull 1 I it d i apactbns. C9rw late drawing o averse ids. - J/ [_ ��,��,�4 Signe6 FIC L'I/1-� H-F I itis II 1 Date: / FO EP T \ENT USE Ly �O Application Accepted by Dots Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services e--) Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE CK RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REM[H�ITTED CASH 1 r�rf� . EN 13,24(REV.r,n at . o •V ° ` 3 EH L62a