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7 1«" n APPLICATION FOR PERMIT �!� r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A��°' ENVIRONMENTAL HEALTH DIVISION JE CLrl �® 1601 E. HAZELTON AVE. , PHONE (209)468-3420 JUN P O BOX 2009, STOCKTON, CA 95201 SqH� 0 3 tgp1 PUBLIC OAQUIly t PEMIT EXPIRES 1 YEAR FROM DATE I SSUW!ROjl P4EN A�NH SSP�ICES (Complete in Triplicate) FALTHDIVISIO, Application is hereby made.to Ban 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 City T'RAQXLot Size/Acreage NIA 2360 BUCHANAN RD. SAN- JOSE CA (415)827-6195 Owner's Name 1a��F�La-rn�rp,r>�r�n�._., Address Phone 65F 5) 4,87-4"WMILL VALLEY CA 94941:.: Con tractor AMERICAN CONSTRUCTION Addressl038 REDWOOD HWY #2 License No. —a Qi99 Phone TYPE OF WELL/PUMP: NEW WEI_LU WELL REPLACEMENT 71 DESTRUCTION ❑,Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0OTHER ❑ µ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK, NONE SEWER LINES_ NSA " DISPOSAL FLD, NONE PROP, LINE 150' FOUNDATION..15? _;AGRICULTURE WELL;NONE .OTFIER WELL NONE _.PI TS/SUMPS I�O�ISE � INTENDED USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C} Industrial - ❑ Open Bottom ❑ Manteca f Dia. of Well Excavation Dia. of Well Casing 2"(VENT) ['I bomestic/Private ❑ Gravel Pack C1Tracy,"y 4 Type of Casing SAH 40 PVC Specifications 1"1 Public Na Other n Delta , Depth of Grout Seal 140 t Type of Grout? SACK SAND T f I I Irrigation 264 Approx•'Depth I I Eastern Surface Seal Installed by AMERICAN CEMENTSLURRY Repair Work Done 0 Type of Pump H.P. # `' State Work Done w Welt Destruction ❑ Well Diameter Sealing Material & Depth P Depth " "— - Piller.Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence=} Commercial_ Other Number of living units: Number of bedrooms�` � Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK 0 Type/Mfg ` Capacity No. Compartments PKG. TREATMENT PLT, 0 ' # Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to'nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number t s _ SUMPS '"CI Distance to nearost:`�'"WeII""` ®'Foundation a Property 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 J6aquin 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 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." I f The applicant s call f�lrraallrequired inspections. Complete drawing on reverse side. Signed LiXJ STEVE McKIM Title: PROJECT MANAGER Date: MAY 303, 19911, FOR EPARTMENT USE ONLY Application Accepted by -"A" f Date .Area Pit r Grou inspection by ate Final Inspection by Date_� Additional Comments: e1, -- / r Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services ` 1601 S. Haxelton Ave., P 0 Box 2009, Stockton; CA 95201 FEEAMOUNT DUE AMOUNT REMITTED KAV INFO H RECEIVED BY DATE PERMITNO. . EH1 3.211REV.I/H51 EH 14.26pi/ CIA J I I