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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 KA JOB (209) 468-3447 20-Y92-045 R PROM DATE ISSUED omplete in Triplicate) Applicatio s hereby mac to an oaquin Co ty for a permit to construct and/or install the vork 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. APN NO. 195-270-61 BIG VALLEY FACTORY STORES Job Address E. of Harlan Rd. ,aprox.600' So.of Louise City Lathrop Lot Size/Acreage Owner's Name Willey Creek. Company;_ InAddress 1788 Tribute Road,, Suite 300 Phone ,6y9"3 Contractor Spectrum/Kleinfelder Address 2825 E. Myrtle St. License No. 512268 Phone 948-1345 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Otrl-tst3crtrtce-iful-r--1 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER IN MonalAw-lag.ye'Ll (I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 9944-1614E 16 Test Borings FOUNDATION AGRICULTURE WELL OTHER WELL PI g8 &I~S 10'to25'Deep INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial. © Open Bottom ❑ Manteca Dia. of Weil Excavation f3ia*�f-�4�elGsing ; U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing SpeerlioatioF+a ❑ Public 1-1 Other ❑ Delta Depth of Grout Seal Twee-e(-4r*reat If GW `A vl 0 Irrigation Approx. Depth C) Eastern will Eastern Surface Seal Installed by backfill with Repair Work Done 0 Type of Pump H,P. State Work Done _ Wall Destruction O Well Diameter Sealing Material A Depth "Hole ug Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIWADDITION LT DESTRUCTION Cl (No 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity-- No. Compartments' PKG. TREATMENT PLT,0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED 171 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number V 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 eine in accordance with San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin county Home owner or licensed agent's signature certifies the following: "I certify that n 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 compensati--,laws of California," Contractor's hiring or sub-contracting signature canifies the following: "I certify that in the performance of the work for which this pe!+mit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for required inspections. Complete drawing on reverse side. Signed Title: Engineering Geologist Date:April 7, 1992 FOR' E? TMENT USE ONLY'` Application Accepted by Date - �~ a Pit or Grout Inspection by _� Date _ Final Inspection b y Datr &� I Additional Comments: � r - Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REWtTTED CK INFO CASH RECEIVED By DATE PERMIT N0. . EH13.24IREV.11N5)SIV _Tuc If !~ I��OV`r f EH 14.2e