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/ APPLICATION FOR PERMIT ^,)/ ,gr� •i SAW JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ", t2 1992 � P O BOX 2009, STOCKTON, CA 95201 ,Illyd ,,Ill��y O (209) 468-3447 11I':ERVI(1ES PERMIT EXPIRES 1 YEAR PROM DATE I SUE6 tdit' 'bihilW611 WTI ib B-3 (Complete in Triplicate) Application Is hereby aide 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 theElul and f Up Joaquin County Public Health Services. ly Job Address 24 So. Hunter Street City Stockton Lot Sim cr c S Owner's Name San Joaquin Co . Address 222 E. Weber St . , Room 675 Phone 209-468-3252 Spectrum Contractor Exploration Address 2825 Myrtle St . License No. Phone 209-465-8 12 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EBor M,tiitoring Mell ❑ DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINESappr. 55' DISPOSAL FLD.+150 t PROP. LINE aDDr. 10, FOUNDATION 3-6 t AGRICULTURE WELL +150 ' OTHER WELL-±-150' PITS/SUMPS +150 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (I Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Grovel Pack CJ Tracy Type of Casing Specifications 0 Public I:1 Other ❑ Delta Depth of Grout Seal Type of Grout Neat Cemen B6 Els- ❑ Initiation _.Approx. Depth ❑ Eastern Surface Seal Installed by Bentonite Slurry Repair Work Done U Type of Pump H.P. Stay Work Done, Well Destruction ❑ Well Diameter Beeline Material a Depth Neat Cement /Bentonite Slurry Soil Sampling Depth Filler Material L Depth Same TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION Cl DESTRUCTION CI INo septic system permitted if public fewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other (\ Number of living unite _ Number of bedrooms J 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 .n\ LEACHING LINE Cl No. a Length of lines Total length/tire {V� 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 PONDS ❑ I 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 Sen 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: "1 certify th t in the rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of dor Is." ual call for I e uirad In The applicaript 'ons, plate drawing onn/heverse side. X !� Signed X C/VIITltls: M Dote: FOR DEPARTMENT USE ONLY '1 ,.q, �2"� UI APPlicnlon Accepted by tA�� Dote �/`� 1Z Area �J Z3 Pit or Grout Inspection by Date Final Inspection by Date Additlonal Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 93201 FEE AMOUNT UE 101:1, 111 nIFI OINFO K RECEIVED BY D TE PERMIT JNO14)241111w.1'.51 Sa 7E7 FN:I Se