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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �— 43 ENVIRONMENTAL HEALTH DIVISION 445 N SOXJ2009, STOCKTON(20A )95201420 PO70,55- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l 1,/61/(44r, (Complete in Triplicate) filth� �� n,'� j� /S�Application is hereby made.to San Joaquin County for a permit to construct and/or instawork herein described. This`v application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San 's Joaquin County Public Health Services. Job Address 10221 E. Baker Rd., City Stockton Lot Size/Acreage 25 (�tC a�aES Owner's Name Wi.11iain Doscher Address 12600 E. Eight Mile Rd,., Skin _ Phone ConlractorPuryiance Drillers,II101ddress P. O. Box 64,LindenCA License No. 377923 Phone$87-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ER DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION IN SYSTEM REPAIR L7 OTHER ❑ Monitoring 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 fl Industrial ❑ Open Bottom ❑ Manteca Dia.,of Well Excavation Dia. of Well Casing 12 3/4 LI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing � t?�1 Specifications—•188 J 1'I Public I 1 Other f� Delta Depth of Grout Seal Q Type of GroutcementI_) Repair Work Done x. Depth I I Eastern Surface Seal Installed by q sK /fit Repair Work Done ❑ Type of Pump X, H.P. X State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial_. Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity__ No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size 'S FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI 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 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 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 a��ca7a' $' calf for quip fnsP,811��'Ons* omplete drawing on reverse side. Signed`x> �� Date: Title: Corp. Secretary 4/19/93 FO TMENT USE ONLY Application Accepted by Date - _ Area 0 � r Pito Gr t Inspection by ate Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE dPEMIT•N0. EH1324(REV.rins) WV— t0� ` 'yw'EH 14 2a u� 17 �� 1 9