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APPLICATION FOR PERMIT SAN JCiRQUIN COUNTY PUBLIC HEALTH SINVIVICES ENVIRONMENTAL HEALTH DIVISION *REFER TO WORKPLAN 445 N SAN JOAQUIN, PHONE (209)468-3420 FOR DEPTHS AND P O BOX 2009, STOCKTON, CA 95201 SPECIFICATIONS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sam 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 1804 West Main Street City Stock on Lot Size/Acreage 108,000 SF East Bay Municipal Utility Owner's Name District Address 375 11th Street, Oakland, CA Phone 510/287-1663 Palo Contractor HEW Drilling Co. Address P.O. Bog 51182, Alto,CALicense No604987 Phone 415 322-2851 *TYPE OF WELL/PUMP: NEW WELL E WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well 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 C) Industrial O Open Bottom O Manteca Dia. of Well Excavation 11" Dia. of Well Casing Orr El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications SCh. 40 1.1 Public R,1 Other (l Delta Depth of Grout Seal Type of Grout Cement— I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by HEW Drilling Co. Bentonite -- Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth 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 Character of soft to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 6 Length of lines Total length/size_ FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby cenify 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, 1 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 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 must call for all r d i tronspections. fete drawing on reverse side. Sip Title: l� R 5 , Date: FOR DEPARTMENT USE ONLY Application Accepted by G] Dat 'IN Area ,� 2 �j/( Pit or Grout Inspection by Date ? 9 (-� Final Inspection byNl_gbiLl Dates Z L-"4 Additional Comments:gAs*5 : I#�5 # Applicant - Return all copies to San Joa in County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH R EIVED By DATE PERMIT'NO. EM 14.24INEV.1,ti5t Sq fro 89.E 2 3 8-1 �-93 3-1 EN 11.2!