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--Ail- - - - - APPLICATION v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388,STOCKTON,CA 95201-0388 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 r Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 601 NORTH SACRAMENTO STREET City LOBI Lot Size/Acreage _ 0.43 Owner's Name LEONA GUGLIMItTTTIan Address 601 NORTH SACRAMENTO_STREET Phone - Contractor N/A f ' Address �3 d� ' License No. Phone TYPE Of WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of 9 rvice Well ❑ PUMP INSTALLATION G SYSTEM REPAIR O OTHER ❑ 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 El Industrial ❑ Open Bottom © Manteci Dia. o1 Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'1 Public KI Other �UA PG§UGERn Delta Depth of Grout Seal Type of Grout I I Irrigation 1 •SPTApprox. Depth I 1 Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth BENTONITE CHIPS - Depth Filler Material i Depth TYPE OF�SEPTIC WORK:, NEW INSTALLATION t I REPAIR/ADDITION I I__.DESTRUCTION I I fNo.t:epr.ic system permitted it aub.lic_w_ war is available within 290 feel.l Installation will serve: Residence— Commercial_ Other 7 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. Cl Method of Disposal Distance to nearest: Well Foundation Property Line ? LEACHING LINE Ll No. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Wel! Foundation Property Line SEEPAGE PITS 11 Depth Sire Number 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 perlormance 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 certifies the following: "I certify that in the performance of the work for which this permit is issued,I shelf employ persons subject to workman's compensa- tion laws of California." The appli ust calf IQr all required ' coons. Complete drawing on reverse side. Signed tom/ Title: PROJECT MANAGER Date: 7/14/95 FOR EPARTMENT USE ONLY L �] Application Accepted by Date Area / Pit or Grout Inspection by 25 Data Final Impaction by "� Date / 2u Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �^ e , Environmental Health Permit/Services P o 445 N.Sen Joaquin,P.O.Box 388,Stockton,CA 95201-0388 a7 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECE"D 9Y OATE PERMIT-NO. . I 13.24 IRE ,I/NSI 3 AyZ. fir 11"7a