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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONYENT'`TTHIiALTH DIVISION 1601 HAZELTON AVE. , PHONE (209)4-3420 0 BOX 2009, STOCKTON , CA 95 PERMIT EXPIRES 1 YEAR FROM- 2,17 E 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 Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1624 East Alpine Avenue city Stockton tot Bite/Acreage 12.6 Acres Owner's Name Kearney-RPF Address 1624 East Alpine Avenue Phone 209 ) 464-838 Contractor * Address License No. Phone TYPE OF WELL/PUMPNEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of 8ervlce Well ❑ PUMP INSTALLATION 01 SYSTEM REPAIR ❑ OTHER OMooniitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP LIFE it "rin IS FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 10t4i0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS —/ O Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing fl Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications I'I Public 17 Other n Delta Depth of Grout Seal _ Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth �- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other \ Number of living units: _ Number of bedrooms `4- Character ofta-a Water table depth SEPTIC TANK j) 1�� ' M Capacity No. Compartments S � i1 PKG. TREATMEN'ff,PCT. O zll �� Method of Disposal Distance to nearest: Well Foundation Property Line w Ltt o. eng Lth of lines Total length/sizeLEACHING LINE L FILTER BED CNVIRgNMENTPS��RVrest: Well Foundation Property Line SEEPAGE PITS t1T epth• Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS O 1 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 candies 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this perrtdt is issued, 1 Mall employ persons subject to workman's compensa. tion Iowa of California." The applicant 7sfor alll required insp/ec_/t��?�.i.�)Comp lets drawing on reverse ship. / Signed 1=F'/-:-9 Title: ' / Date: f0ARTM SE ONLY Application Accepted by / Date` v �/ / 'Are Pit or Grout Inspection br Data/V� ,Final Inspection b ��Date — G—% Additional Comments: *refer to iGx'oundwater Assessment Report, Kearn PF" for details Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Raselton Ave., P 0 Box 2009, Stockton, CA 95201 / J INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATE IERM17'NO. EH I;3.24 IaEV.vest EM t 428 •' � , I OG �TRxL �1r.�' /V-, 5/