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SAN ,J�OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE. ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 10221 E. Baker Rd., City Stockton Lot Size/Acreage 25 N-C-t 5, <br /> Owner's Name William Doscher Address 12600E Eight Mile Rd , Stkn Phone <br /> ContractorPurviance Drillers,Intwdress P. O._ Box 64rLindenCA License No. 377923 Phone87- 554 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT X DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION (N SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial CTO pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 12 3 A <br /> F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Steel Specifications188 <br /> Cl Other n <br /> I"1 Public — • ,- <br /> Delta Depth of Grout Seald� Type of GroutCeTtP11t . <br /> ( ' <br /> Irrigation 425Approx. Depth I I Eastern Surface Seal Installed byX I" <br /> Repair Work Done U Type of Pumps— <br /> H.P. X State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial_• Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS 11 Depth Size <br /> Number <br /> SUMPS <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The a can at call for II equir inspections. Complete drawing on reverse side. <br /> Signed Corp.�(/7 Title: Secretary 4/19/93 <br /> Date: <br /> FO ENT USE ONLY <br /> Application Accepted by Date 3 Area 02 <br /> Pito Gr t Inspection by ate <br /> final Inspection by Date d 9 <br /> Additional Comments: l4 awl /&J, <br /> Applicant - Return all copies to: San Joaquin County Public Health Services '�� <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNTDUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 124IREV.rin5lW 4 <br /> EH 11.4.2a <br />