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- APPLICATION FOR PERMIT w F BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 KA JOB L/03 (209) 468-3447 20-2768-69 VIP ✓ ✓ 1 AERMTT EXPIRES 1 YEAR VRQK DATE IUSUI 3� g� S• 9� (Complete in Triplicate) X143 C. 9 Application is hereby made to Sap 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. APN 179-18-02,03,14,13 & 11 .LITTLE JOHN CREEK SUBDIVISION Between State Hi hwa 99! & Pock Ln, City Stockton Lot Size/Acreage f Job Address g y` Stockton,Ca. 95205 Owner's Name Address Verner Construction 2707 E. ' Fremont St. , Su. 5 Phone � — -- Contractor Spectrum/Kleinfeldel,ddress 2825 E. Myrtle St. License No. 512268 Phone 948-1345 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION-Ll VatOf Ora,vtce-iW?633--a PUMP INSTALLATION © SYSTEM REPAIR 0 OTHER � �nirtt7rt- � T DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. =-�P-tINE�est Bor ngs FOUNDATION AGRICULTURE WELL OTHER WELL -PtTS75OfvlPS 10}-15t De p . Dia. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS No f�W n industrial ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Sia-ei-I+yeIF Easing Anticipated U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing 9pecthtatrans�. M Public f 1 Other ❑ Delta Depth of Grout Seal fitpevF6raar 0 Irripauon Approx. ❑ Eastern Surface Seal Installed by encountered will Repair Work Done U Type.of Pump H.P, State Work Done _ ac i with I'Hole Plug" Well Sealing Material 4 Depth Destruction © Weil Diameter (� Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION.❑ REPAIRIADOITION 71 DESTRUCTION CI (No septic system permitted if public sewer is 110 available within 200 feet.) Installation will serve: Residence— Commercial- Other Number of living units: Number of bedrooms ` Character of *oil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, I shell not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall employ parsons subject to workman's compansa• tion laws of California." The applicant m t call for all squired inspections. Complete drawing on reverse side, Signed X Title: Engineering Geologist Date: 1-4-91 I FOR PA MENT USE ONLY i I Application Accepted byIf Date Area c, Pit or Grout Inspection by Date Final Inspection by Date l- Z� r Additional Comments: N - Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO 1 �1 ,■RVn► {� �}+ ��q�� EH13.24(REV,I/it 1[ R - 440 ! "6t+ e