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• APPLICATION FOR PERMIT 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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. Job Address 25775 PatteL'son Pass Pd (CDLElty Rei) city TI:My Lot Size/Acreage 33 OCO ft Owner's llama PRM ProdLcts Carte_ Address P 0 Box 5811San %teo, CA 94402 Phone(415) 571-2469 Contractor ,estex Strata Exploration Address P 0 BOX 1664, W. Sa=aTMtOLicense No. 552198 Phone 916- 373-1118 TYPE OF WELL/PUMP' NEW WELL Vapor- WELL REPLACEMENT Ci DESTRUCTION Ll out of Service Well 0 Monitoring Well ❑ PUMP INSTALLATION ❑ eXtL2Ct1Cn SYSTEM REPAIR El J�OTHER OOP LINE S� DISTANCE TO NEAREST: SEPTIC TANK N A SEWER LINES TTTT//,^� DISPOSAL FLD. �p�� FOUNDATION Ste ❑LTJ AGRICULTURE WELL � OTHER WELL PITS/SUMPS WA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 4 inch 0 Industrial O Open Bottom 0 Manteca Dia. of Well Excavation _ T of Casing � 40 � Specifications Cl Domestic/Private ❑ Gravel Pack �] Tracy Type W---�— Type of GroutlgitCLiltefCarM I"I Public Cl Other fl Delta Depth of Grout Seal I I Irrigation 45-82 Approx. Depth I I Eastern Surface Seal Installed by Driller H p I State Work Done _ Repair Work Done 0 Type of Pump Sealing Itaterial a Depth Wall Destruction ❑ Well Demeter Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOtTION I I DESTRUCTION I I INo septic system permitted II public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of sod to a depth of 3 feat: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest•. Well Foundation Property Line LEACHING LINE 0 No. A Length of linea Total length/size FILTER BED 0 Distance to rtarest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to mares): Wall Foundation Property Lina DISPOSAL PONDS ❑ 1 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 re fuletiona of the San Joaquin County : "I certify that in the performance of the work for which this permit is iuuain I shell not Home owner or licensed agent's signature certifies the following employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sulrcontrscting signature certifies the following: "I certify that in the pertormanca of the work for which this permit is issued, I snail employ persons subject to workman's compensa- tion laws of California." The applicant call for }Il r lr nsPt•ctlont Complete drawingon revers side. Title: r, Data: /2 - Signed �.✓'�(� FOR DEPARTME T USE ONLY T Application Accepted by -N� Dan Area ,✓1�c.� r � Ph or Grout Inspection by � =—rte-- Date la� Final Inspection b�' ' ` • Den/ Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services �Y G Environmental Health Permit/Services �� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No . � Q7 ,..ice