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z � �" ! r'• ""' APPLICATION FOR PERMIT' N h SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 I HERMIT EXPIRES 1 YEAR FROM DAJE ISSUED (Complete i nSa j8A4 tbUM-pL1BLICHBALT'S SUVICW Application is hereby made to San Joaquin Count for r Qbh%i Yrs&LIW d �D-i ShcN PP Y q y permit to const ere n described. This application is made in compliance with San Joaquin County Ordinance No. 51� r1$(�aod„the�t�tijyJ�t�itions of San Joaquin County Public Health Services. J !tJ' ��LL �r�riijl�tll�rll Job Address 141 F1 Dorado City Stockton Lot Size/Acreage C.M. Weber Enterprises Ca. 95818 Owner's Name Gurtrude Weber Addre s 3757 College Ave Sacramento Phone 916/443-1561 �c vr` � i - 4 SG 78 Contractor^ PC Exploration Address 1780 Vernon Sto ,#1F_ License No.265556 Phone 916/783-9723 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER M Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 20 feet DISPOSAL FLD. PROP. LINE 10 feet FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10-inch Dia. of Well Casing 4-inch fa Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Schedule 40 PVC Specifications I.1 Public IX Other 3 Ws s n Delta Depth of Grout Seal ±_0_t0_ 30_feet Type of Grout_._LeMent I I Irrigation 40 t0 -453kpprox. Depth 11 Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump N/A H.P. _ N/A State Work Done_ Well Destruction ❑ Well Diameter NIA Sealing Material i Depth Depth Filler Material 0 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) N 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 ❑ T e/M! t Yp g Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line O SEEPAGE PITS 11 Depth Size Number fi SUMPS LI Distance to nearest: 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 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 cenifies 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 mu c I required inspections. Complete drawing ons reverse side, �{,, Signed 6,�G�^-'� Title: V T L Sh11LI- tj11 ��ate:rILT rb st);17- 21—,19(0 .q,— FVD E PA NT USE ONLY Q Application Accepted by Date ! Area Pit or Grout inspection by Date4K_ Final Inspection by Date 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 y INFO AMOUNT DUE AMOUNT�R!EMITTED CK ill CASH RECEIVED BY DATE PERMIT'NO. . EH 13-24 IREv.rin31 EH".420