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a APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 i 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. xSTOCKTON e Job Address �.' �h S Ci,y_ Lot Size/Acres g QUAIL LAKES LAKE FRONT^� OWNERS ASSOC . �51T--13q-7 Owner's Name Address p-�().BOX 7625 , STOCKTON- Phone ContractorNENNINGS BROS. DRILL. Address 3525 PELANDALE—MOD-9535liicense Ivo. 290813 phone 545- 1185 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ 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 rr 1 rl �. Ll Industrial C3 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,4 'k N Domestic]Private. d(Gravei Pack 0 Tracy Type of Casing__STEEL Specifications V CFMFNI C, I'l Public FI Ot jer i-1 Delta Depth of Grout Seal 50 r Type of Grout IX Irrigation cR_10Approx, Depth I I Eastern Surface Seal Installed by H 5 N N I N G S BROS. DRILLING Repair Work DoneY {]. Type of Pump H.P. ____ ____ State Work Done _ IG Well Destruction ❑ Weil Diameter Sealing Material & Depth - Depth _ 0 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITInN I I DESTRUCTION I ! INo septic system permitted if public sewer is available within 200 feet.) .P$Z ik 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. 0 Method of Disposal Distance to nearest: Well foundation Property Line. LEACHING LINE ❑ No. & Length of lines Total length/size _ Y FILTER BED n Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS 11 Depth Sire 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 iri 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 therperformance 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." The applicant must call for ail required inspections. Cortppl to ffrawin reverse side. + Signed X Tttl Date: 6-16-93 OR DEPART E USE ONLY Application Accepted by Date Area '— Pit or Grout Inspection by Date Final Inspection by 6te i Additional Comments: d-0 &D ci_ w —+`k' _ 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 I CK RECEIVED BY DATE PERMIT'NO. INFO t�.yrt� CASH( . EH 13-24(REV, i EH 14.26