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a APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH MVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE 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. L Job Address 2905 West Ber►%amif ., No if De. �;,y Stoe'� oH Lot Size/Acreage �J Owner's Name GhGyrm ProdyetS C,-� Address 21110 Camino Ramon Phone SIP 1?g2'95CD Contractor�Dr�S /Dl'a7rOM�wf6ddress P �9S License No.C51g2 � Phone 707 yS292 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Fl DESTRUCTION n Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK Us"60'ItIA SEWER LINES NA DISPOSAL FLO.4_ PROP. LINW • FOUNDATION 7S� AGRICULTURE WELL _NA OTHER WELL `1ST}' PITS/SUMPS IJA- INTENDED USE NA TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation 2 on. Dia. of Well Casing 'n f l Domestic/Private ❑ GG' vheel Pack C3 Tracy Type of Casings�40 PYL Specifications :. I'1 Public ( Otr Fl Delta Depth of Grout Seal 5E"• Type of Grout ae ani A 18�k I I Irrigation 2�]R-Approx. Depth I 1 Eastern Surface Seal Installed by Dr )lar Repair Work Done U Type of Pump _N A H.P. A State Wor one_ Well Destruction O Well Diameter N A _ Sealing Material i Depth Ppirfland hVi caYn f Depth A(A Filler Material i Depth -93 44.1d /✓ 2,0H• TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower 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. O Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number 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 done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen Joaquin County Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 Californla.'• Theant at call fo r ins tons. ¢or9ete drawing on reverse side. �Gi1 rf Ooh Sig Title: s17 �G0�61��5� Date: e /'O 3 FOR DEPARTMENT USE ONLY / Applic t n Accepted by Date D Area S. / Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y DATE PERMIT*NO. • EMc7.1� 1 16t)33�S EH 11.1!