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SAY'OAQUIN COUNTY PUBLIC HTALTE' "ERVICES `� ENVIRONI MAL HEALTH DIVI61 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOMON, ItCA 95201 Complete in Triplicate)' Applications is hereby, made to San Joaquin County for a permit to conatructlland/or install the work herein described. This application is made 1A compliance with San Joaquin County ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. tJob Address 7759 SOUTH AIRPOR WAY City STCKTON 'Lot Size/Acreage A_ PPROX. 6 _AC_ i SAN JOA UIN COUNTY i}. Owner Ia Name MOSQUITO AND VECTOR TRLAddress 7759 SOUTH AIRPORT WAX Phone 209 982--4675 DISTRICT.. 3Z�� l cSiJft�;2 Contractor v l Address 5T*� Z License No. � Pho,t6wwww TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Vel -10 I PUMP INSTALLATION (3 SYSTEM REPAIR ElOTHER O Monitoring Well X0 DISTANCE TO NEAREST: SEPTIC TANK >50' SEWER LINES 10' bISPOSAL FLD. >50' PROP. LINE ],Q� FOUNDATION 10r AGRICULTURE WELL!t L OTHER WELL Jnr "PITS/SUMPS 7501 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing 2 INCH n Domestic/Private ❑ Gravel Pack O Tracy Type of Casing PVC Specifications SCHED 40 Il Public n Other I-1 Delta Depth of Grout Seal I� APPROX 40-42' ..Type of Grout 57 BENTONITE CEM_ I k Irrigation —Approx. Depth I I Eastern Surface Seal Installed�by DRILLER ENT Repair Work Done U Type of Pump N/A N.P. I State Work Done _ Well Destruction ❑ Well Diameter N/A Sealing Material A Depth 1'� Depth N/A Piller Material i Depth PTIC WORK. NEW INSTALLATION 11 REPAIRIADDITION I I DESTRUCTION I I c system permitted it public sewer is within 200 feet.) Installation will serve: Residence _ CommerciN _ 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. I No. Compartments -PKG. TREATMENT PLT. D . . IMethod of Disposal Distance to nearest Well Foundation Property Line I� LEACHING LINE 0 No. 6 Length of lines FILTER 8ED O Distance to nearest: SEEPAGE PITS SUMPS DISPOSAL PONDS Well Foundation Property Line [ I Depth Size Number LI Distance to nearest: Well Foundation II Property Line V1 I hereby certify that I have prepared this application and that the work will be done in accor6nce with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Counter r 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." Contractors hiring or sub -contracting signature tfo certifies the fowing: "I certify that in the pertomtanes of the work for which this permit is issued, I @hail employ persons subject to workman's compensa- tion laws of California." �� The applica mat cult r al ulred inspections. Complete drawing on reverse side, IF Signed 1WTitle: GEOLOGIST (ROY F. WESTON) } Date. �„ FOR DEPARTMENT USE ONLY' Application Accepted by Date 1 ` Area Pit or Grout Inspection by Date Find Inspection, by Oats Additional Comments: I Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stka, CA 95201 FEE it INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT -NO. . EH U-21 tRt\r, tins) FM 11.7a