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3 APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES COPYENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is hereby made.to San Joaquin County for a permit to construct and/or install the vont herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules a.ad Regulations of San � Joaquin County public liaalth Services. PJ,b Address 5405 East _P=o fano Lane____— __ City _c;'l-nC1Ct0n Lot Size/Acreage 138 acres Gertrude M. Weber Trust Owner's Name Address 3757 College Avenue, Sacto. Phone (916) 443-156' 3252 Polk Way, Stockton, CA � Con raclor13r +- Inc- License No. 3d3?Q7 Phone(209) 944-9 55 TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT n DESTRUCTION 0 Out of Service We21 El PUMP INSTALLATION ❑ SYSTEM RE AIR ❑ OTHER ❑ Monitoring Well L3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION CULTURE WEL OTHER WELL PITS/SUMPS ._._ INTENDED USE TYPE OF WELL PROA LEM AREA ONS UCTION SPECIFICATIONS n Ihdustrial Open Bottom p M nteca Dia all Excavation pia- of Well Casing { CI Domestic/Private ❑ Gravel Pack ❑ T acy T pe of Cast Specifications I'I Plublic f-1 Other Cl Its epth of Grout Seal Type of Grout L. I ► Irrigation Apprax. Depth I I E flarn Surface Seal Installed by Q 1, Repair Work Done 0 Type of Pump H State Work Dona Well Destruction 13 Well Diameter frig Material a Depth v, Depth Filler Material i Depth do TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIRrADt]I71gN I I DESTRUCTION (No septic system permitted if public sewer is (� vailaWe within 200 feet.i � 1 will serve-wserve: 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 Type1Mfg Capacity No. Compartments t PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. b Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth ---- — Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line l 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 sews, 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, 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 cenify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion Iowa of California." The apptica or all ions. plate drawing on reverse side. Vice-President Anri? ,7 , 1393 Sig d Title: Date: F DEPARTMENT USE ONLY Application Accepted by r M M� ""� A-- Dots 1 !-l.� Area ' Pit or Grout Inspection by Data—.Final Inspection by Date fe Additional Comments•. IAppllcant - Return all copies to: San Joaquin County Public Health Services Euviroamental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK 9 INFO AMOUNT DUE MOUNT. CASH RECEIVED By DATE PERMiT•NO. • EM,}2rs(REV.iiKsrO� Err,43e -7