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APPLICATION FOR PERMIT 4 r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 9C 1601 E. HAZELTON AVE. , PHONE (209)468-342 O [Py D V P 0 BOX 2009, STOC%TON, 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 Count) Job Address 6855 W. Eight Mile Road T City Stockton Lot Size/Acreage Owner's Name U.S. SPrint Address D 0 Roy RU90 Kan— City— Phone - 3059 MO 64114 Contractor WFGTFX Address n Box 1661 W Car License No. c5e#552198Phonj916)373-111 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out ofservicewell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER (X -Mo itgringFWell 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -,r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G�}rtdustrial '✓ n Bottom ❑ Manteca Dia. of Well Excavation�-6ff Dia. of Well Casing (rr[ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing N/A Specifications 1 Public 1-1 Other 11 Delta Depth of Grout Seal N/A Type of Grout rPmant I I Irrigation 1444pprox. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. 5 Well Destruction ❑ Well Diameter Sealing Material & Depth 4-StateWork Done Grou to full dept Depth Filler Material i Depth 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.) 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 ❑ No. & Length of lines Total length/size 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 PONOS ❑ 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 su contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p sons sublet workman's ompensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse sidd�7lfG'��` �� Signed X r Title: t c'Cavl. C-�/Gra41 ate: tZ 3- `uo A J cw Sh U rW FOR DE ARTMENT USE ONLY / ,L O // bb. Application Accepted by may, (,Z.-, Date /Z/4'420 Area 3W Pit or Grout Inspection by - Date f `/ �U Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Servlcea, EnviroTame ntal Health Permit/Services 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASN }�) ' / �/� . EH 1124(REV.1r n 5) ((� moi(^ Ofi .LI `I �� '^'l4�i Il. f� EH 4-211