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!` APPLICATION FOR PERMIT E SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468--3420 P O BOA 2009, STOCKTON, CA 95201 f PFR [IT 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 work herein described. This (application is made in compliance With San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. i 11L49 )Job Address City StoC•ktnnLot Size/Acreage Owner's Name Bank of S toyckton Address Phone i�Contractor_ -West Ha7.mat Address_3233 Fitzgerald License No. 554979 Phone 76 ' JYPE OF WELL/PUMP: NEW WELL lk WELL REPLACEMENT l_ DESTRUCTION ❑ Out of Service Well ❑ �I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well !DISTANCE TO NEAREST: SEPTIC TANK Tl/a SEWER LINES _ __ -1001 DISPOSAL FLO. PROP. LINE r i :I FOUNDATION 5(1! AGRICULTURE WELL OTHER WELL 2 4 r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I'C7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4 'r jr ,Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 5 shed 40 PVC Specifications f"1 Public k1 Other sand pkn Delta Depth of Grout Seal ' Type of Grout_-dmf 1 t Ii Irrigation 2-5-4.Approx. Depth I I Eastern Surface Seal Installed by �Cj- 11.-1.05 ;Repair Work Done ❑ Type of Pump H.P. State Work Done IWelf Destruction ❑ Well Diameter Sealing Material,,& Depth _ be i3 t en 4:t e Depth Filler Material & Depth i TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other it Number of living units: Number of bedrooms I k Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal II Distance to nearest: Well Foundation Property Line ' LEACHING LINE 0 No. & Length of lines Total length/size ` FILTER BED C) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 ) Depth Size Number SUMPS LI Distance to nearest: Wel! Foundation Property Line t`O 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 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature cartifies the following: "I certify that in the performance of the work for which this permit is issued, !shall employ persons subject to workman's compensa tion Laws of Cali_ rnia." The applicant st ca for alred inspections. Complete drawing on reverse side. iI •- Signed X____, _ Title: Date: 11/7/91 DEPARTMENT USE ONLY Application Accepted by Date � L Area �i Pit or Grout Inspection by �" Date �O qZ Final Inspection by Date 12—✓� Z ia: f- 1 5 � Additional Comments: ii Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 4 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE '- AMOUNT DUE AMOUNT REMITTER CAS INFO H RECEIVED 8Y DATE PERM17 N0. If r� a Eti13-24[REV.1/N51 U DO ��. DO rjy,�2 w1VV11 �5 (2 Q J 1-3[ r EH 74.29 f�