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r ! - APPLICATION SANeJOAQUIN COUNTY PUBLIC HEALTeSERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT 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 3430 S. E1 Dorado City 31ockton Lot Size/Acreage N/A ( Owner's Name Bank of Stockton Address P. O. Box 1110 Phone ( 209 ) 941-13-)5 Contractor Ai"T" t D i Add est/1803 W March Ln. License No. Phone956-0264 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ Monitoring Well B DISTANCE TO NEAREST: SEPTIC TANK N/A _ SEWER LINES 100Ft . DISPOSAL FLD. N/A PROP. LINE 75 Ft. FOUNDATION 50 Ft• AGRICULTURE WELL N/A OTHER WELL-P-LA— PITS/SUMPS N/A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 [.I Domestic/Private :fit Gravel Pack ❑ Tracy Type of Casing__. PVC Specifications I'I Public Cl Other F1 Delta Depth of Grout Seal AD" Type of Grout Neat' Come n I I Irrigation _.Approx. Depth 1N Eastern Surface Seal Installed by Flush grey Well Cover ti Repair Work Done L3 Type of Pump H.P. State Work Done _ C Well Destruction O Well Diameter 2" Sealing Material i Depth Monitoring Depth 551 Filler Material i Depth (/ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms h Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, O Method of 0 IVED 0 a Distance to nearest: Well Foundation Property Line ItC LEACHING LINE L1 No. & Length of lines _ Total length/size FILTER BED CI Distance to nearest: Well Foundation _ Property Line EIRE) MENTAL HEAL H SEEPAGE PITS II Depth Size __- Number SUMPS LI Distance to nearest: Well_ Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 Californla." The applicant st c fo required isftArtin s. Complete drawing on reverse side/. Signed XZ:a Title: L•,,��7A`> G.�IJ/ Date: S ZOZ_ FOR DEPARTMENT USE ONLY L/ Application Accepted by 7 f`u'.c��/�--•�J .�� / Date DL Area 0Z Pit or Grout Inspection by •/��" ""� Date 4 /17- Final Inspection by " Date Additional Comments: �` ^^� -�lU 021 j ////-(9�" Applicant - Return all copie to: San Joaquin County Public health Services 11 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 9 i+� IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. EH 13-24(REV.rix 5) ' �'�j A /�'yZ EH 1420 (J L .J(! L6