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• APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PIT EXPIRES 1 YEAR FROM DATE ISSUED (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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 535 Center Street City Stockton Lot Size/Acreage 3 acres Owners Name Pacific Gas 5 Electric Address One California St. , S.F. , CA Phone 415)972-1116 94106 Contractor Water Development Corgadress 1202 Kentucky, W00dla11dtic9e No 283326 Phone (916)662-282 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ll DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 1 MAAonniitoring Well L5t DISTANCE TO NEAREST: SEPTIC TANK `^ t nn fi- SEWER LINES DISPOSAL FLD. PRO Lmlf shotes C�/yy ` See map FOUNDATION N 25 £t. AGRICULTURE WELL OTHER WELLN_10f t.PITSISUMPS V " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (PIW-13) ' h Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation 1 2 i nrhpe Dia. of Well Casing 5 inches �l ` CI Oomestic/Private AR Gravel Pack ❑ Tracy Type of Casing PVC Specifications Attached I-I Public I.1 Other fl Delta - Depth of Grout Seal 210 feet Type of Grout Cement (� I I Irrigation 225--ttApprox. Depth 1 I Eastern Surface Seal Installed by ' Repair Work Done LJ Type of Pump None H.P. State Work Done _ OBO star 499 8 inches Sealing Material i Depth Cement grout to y5 feet (b1WB-13, B- 5) -We*Destruction Borehole DepthLi feet Filler Material d Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other l' 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 LI No. 8 Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 1 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: "t 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 workmen'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 mut call for all recut red , iins�jJ�e_Ctions. Complete drawing on reverse side ynl.. �� ` � Signed X 4 c �"`1/I Title: tit PA �wy_ Date: FOR DEPARTMENT USE ONLY J '7 Application Accepted by L w j � /Date " �V Area ,(�' G Pit or Grout Inspection by ' r Dat (� Final Inspection by r Dater l /� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P x 2009, Stockton, CA 95201 ,�J INF REMITTED AMOUNT OUE AMOUNT REMITTED C/KM pR/E�C�EIVVEC BY DATE PERMIT'NO. En 13 24(REV i,.Sr \" � � ('�/. � W/ WLW"•s'Z{( � lG' / :H :r.a