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APPLICATION - <br />,yam <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> SPIVIRONLENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />' (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a perzit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance Ro. 549 and 1862 and the Rules and Regulations of San <br />'i Joaquin County Public Health Services. <br /> Job Address 445 West Weber Avenue City Stockton Lot Size/Acreage 2.5 <br /> Stockton Savings 501 West Weber Avenue (209) <br /> Owner's Name <br /> Bank Address S n A 95202 Phoneq48-6870 <br /> Kennedy/Jenks 303 Second St. , 10th Floor (415) <br /> Ger♦4#ae! r Cgnsultants Address San Francisco. CA —License No. Phone 243-2518 <br /> TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT [-r DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION a SYSTEM REPAIR ❑ OTHER CX Monitoring Well (:3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L1NE5 DISPOSAL FLD. PR <br /> �R.°c Porings) <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C Industrial ❑ Open Sortom 0 Manteca Dia. of Well Excavation 2 inche5 pia. of Wail Casing none <br /> r.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ none Specifications <br /> rl Ptrblic XOthtl4borings)� Delta Depth of Grout Seal less than 15 f Type of Grout cement <br /> I I Irrigation _Approx. Depth ' I I Eastern Surface Seal installed by <br /> Repair Work Done L3 Type of Pump H.P. State wori� Done _ <br /> Well Destruction O Well Diameter Sealing Material i Bepth L <br /> Depth Piller Material i 'Depth <br /> OF SEPTIC WORK: NEW INSTALLATION r I REPAIR/AODtTION i I DESTRUCTION I I INo septic system permitted if public Sawa, <br /> available within 200 feet.) <br />,mak" Installation will Residence— Commercial_ Other I <br /> k Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fee . er table depth <br /> SEPTIC TANK .0 Type/Mfg Capacity No. Compartments - <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well tion Property Line <br /> t <br /> LEACHING LINE ❑ No. & Length of lines I length/size <br /> FILTER BED ❑ Distance ton Well Foundation Line <br /> t <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DIS L PONDS ❑ <br /> Thereby Certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws• and <br /> rules and regulations of the San Joaquin County <br /> 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 shell not <br /> i employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> 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 campensa- <br /> tion laws of Cafifornia." r <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> x <br /> Signed X (RG #6153},ils: Hydrogeologist Date: 13 Oct 95 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Oats <br /> Additional Comments: <br /> F Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health permit/Services <br /> 445 H San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> IFEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. Page 13t� <br /> l <br /> i' <br /> > <br /> 04 13-24 MEv.1 r+r s1 <br /> EH a-2E <br />