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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN2 PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 10221 E. Baker Rd , CityStockton Lot Size/Acreage _25_�C tits g Owner's NameWilliam Doscher Address 12600 E. Eight Mile Rd,Stkn Phone Con IracIoP _iance DrillersRlnc4.ddress P.O.Box 64,Linden License No. 377923 Phone 8 7-3554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 9 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ Monitoring Well U 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 0 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack L1 Tracy Type of Casing_ Specifications N I'l Public fl Other n Delta Depth of Grout Seal Type of Grout CaWpnt_ i $1 Irrigation _,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump Z= H.P. State Work Done_ Well Destruction I Well Diameter Sealing Material & Depth 50' cement- 9sack sand & cei- t Depth __ 1gd Filler Material & Depth from bottom to 50'--backfills TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is (�) available within 200 feet.) V— Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms 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 Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number v 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, I 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." _ Tapplicant at callinI uire inspections. Complete drawing on reverse side. Signet Title: Corporate Secretary 4/19/93 Date: FOR DEPARTMENT USE ONLY Application Accepted by f� [�ti�� ce- ) Date� �,�, ea o'2-�\ Pit or Grout Inspection by Date Final Inspection by y � Date Additional Comments: a"L�if 3/ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO ,, /CAS�H1 !;RECEIVED BY DATE PERMIT'NO.EH 1341 IREV.ri n 51V t d� OD6 f 179! _�, ci3 rl _-1) q�d t0 V EH 11.2E -rI