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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 RECEIVED P 0 BOX 2009, STOCKTON, CA 95201 JAN 15 1993 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Application is hereby trade to Sea 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 2862 and the Rules and Regulatione of San Joaquin County Public Health Services. Job Address 711 Pershing Avenue City Stockton Lot Size/Acreage 0.87 acre Arthur J. Snelt 5461 Covry Crk, Circle, Stockton 478-3218 Owner's Name Charles DeVries Address 23613 E. River Rd. Escalon phone 838-2300 Rancho Cordova, CA 95678 contractor RESNA Industries Address 3164 Gold Camp Dr. #200 License No. N/`°' Phone ?916)852-60 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC,�TIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation LLL. Dia. of Well Casing n/a C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing n a Specifications I'1 Public n Other n Delta Depth of Grout Seal 10 t• Type of Grout Neat Cement I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Contractor � Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION 1 1 [No septic system permitted it public sewer is available within 200 feet.) installation will serve: Residence w.,.. Commercial_._., Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: depth SEPTIC TANK. 0 Type/Mfg j ,rtments PKG. TREATMENT PLT.❑ Disposal Distance to nearest: Well Fou LEACHING LINE ❑ No. 6 Length of lines FILTER BED ❑ Distance to nearest: Well Fo > i SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line 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 regulation 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 parasl is issued, I shall not employ any parson 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 permit is issued, I shall employ persons subject to workman's compensa. tion laws of California." The spplica st call for all rpuirsd inj �tion�s. Complete drawing on reverse side. Signed X. r '`--- Title: Geologist Date: 1/8/93 FOR DEPARTMENT USE ONLY �f� Application Accepted by Oats /fir �J Area Pit or Grout Inspection by Date 11ZA3 Final In tion by �� i,� Date Addhional Comments: Y�w �/� � Applicant - Return all copie to: San Joaquin County Public Health Services p CD Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 LIUJ r INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED AY GATE PERMtT'NO.