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' rAPPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON J CA 95201 PERMIT EXPIRES 1 YEAR FROMI�DATE ISSUED y (Complete in Triplicate)! Application Is hereby made to San Joaquin County for a permit to conatruct''and/o ' install the vork herein described. - application is made in compliance, with San Joaquin County Ordinance No. This 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servlcee. { Job Address 15 ' " t 1� � Yy �V� City St- �ckton' Lot Size/Acreage 2 Acre. I � I lu Catels Dev. CorpOwner's Name _ _- Address 201 Mission.' 30th Floor Phone { San Francisco, 'CA rf — Contractor ERM Address ,I License No. 630406 Phone 510 256-646 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT P 'DESTRUCTION ❑ Out of service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L� ❑ Monitors Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -PROP. LINE. FOUNDATION AGRICULTURE WELL OTHER .WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing 4 inch Cl Domestic/Private Sl Gravel Packs ❑ Tracy Type of Casing_ EVC Specifications U] Public la Other Cl Delta Depth of Grout Seal! Type of Grout I I Irrigation _.Approx. Depth 11 Eastern Surface Seal Installedby Repair Work Done Type of Pump H,P. NA State Work Done, Well Destruction ❑ Well Diameter 4 in j6 Sealing Material 6 Depth Concrete 24 inch x Air S ar in Depth ! Filler Material i Depth ! TYPE OF SEPTIC WORK; NEW INSTALLATION t I REPAIR IADDITION t I DESTRUCTION I I INo septic system permitted if public sewer is -- Not Applicable available within 200_feet.I Installation will serve: Residence_ Commercial X Other Number of living units: Number of bedrooms !! V+ Character of soil to a depth of 3 feet: I�I Water table depth [ SEPTIC TANK ❑ Type/Mfg !_ _ Capacity �� No. Compartments PKG. TREATMENT PLT. ❑ 9 ;� Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line Not Applicable I SEEPAGE PITS I I Depth Size Number, SUMPS LI Distance tonearest: Well Foundation �� Property Line DISPOSAL PONDS C3 I hereby certify that I have prepared this application and that the work will be dons in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Ii Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the w k�f�pr which this permit is issued, I shall not employ any person in Such manner as to ome subject to workman's compensation laws of 2lifornia." C -rBcs h1►i g_ r o#tr cting signature certifies the following: "I ce ,11 that in the performance of the work for which this permit is issued, I shall s piw- ersa eas-to vorkctian's compensa- tion laws of ali}ornla." E IW I/'eC� $.JL( , The applica ust call f r I requir d instions. Complete drawing onFre rse s aAr— Signed Title: o - Date: FOR DEPARTMENT USE ONLY � 1q. Application Accepted by b; . ate Are _ Pit or Grout Inspection by Date Final Inspection by f?afe 1 I� Additional Comments: t Applicant - Return all copies) to: San Joaquin County Public Health!Services G'� {�t�t.I45a Environmental Health Permit/Services .ii 445 N San Joaquin, P O Box 2009, I'Stkn, 'GA 95201V I•I' y FEE AMOUNT DUE I AMOUNT REMITTED CK INFO CASH RECEfVED BY ;i, GATE PERMIT'N0. I EH 13-24 { T • fm 14-�rREv.1/MSI �t�7'i'i f•� I �I �•��`�� Zjqf