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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PA YIIIjE 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 AN SAN JOAQUIN� 3 9g93 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED pU$�)C HEAL COONTV (Complete in Triplicate) ENVIRONMENTALH ,gSTRVICES Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. �h � , application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations or San Joaquin County Public Health Services. Job Address ._._Stockton Airport - 2000 Stimson-Road City Stockton Lot Size/Acreage owners Name Office-:ofa.-the`,State'.Architc�qtress 400 P Street, 5th Floor, Sacrampgtq 916-323-5819 Contractor Westex Drilling Address P.O. Box 1664, W. SacgrpggJ% 552198 Phone 916-373-111 I TYPE Of WELL/ 3 NEW WELL WELL REPLACEMENT C1 DESTRUCTION tri Out of Service Wei 0 I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 7 50' SEWER LINES 7 50' DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f P Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l O Dia. of Well Casing 4" X Domestic/Private QX Gravel Pack C1 Tracy Type of Casing- PVC Specifications I'l Public Cl Other F1 Delta Depth of Grout Seal ,-, 501 Type of Groutcement-bent0 ite I I IrriUation .. —Approx. Depth I I Eastern Surface Saul Installed by _WeStex Drilling _ Repair Work Done L3 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION l i {No septic system permitted if public sewer is available within 200 feet.) j Installation will serve: Residence_ Commercial_ Other �EJ� -:ri3�: •.b. -u,; �- ..V `:l ,v.,.� �.7 xr !,a, :.yX.. f Number of ng units: Number of bedrooms Character of soil to a depth of 3 lest: Water table depth- , SEPTIC TANK OffiCe ^f h- ;131- Ai CilsTeCiPii. Capacity ri,t0TYP o No. Compartments PKG. TREATMENT PLT, ❑ Method o!,Disposal West:_X Dlrji'tat-10 0 . Cir=1464 14 'cif',-Rrni ntf, ,"Z_ t �_r Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size " FILTER BED n Distance to nearest: Well Foundation Property Line f SEEPAGE PITS I I Depth Size Number f� 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, arid rules and regulations of the San Joaquin County ;1 _' ki Home owner or licensed agent's signature certifies the following; "I certify that in the performance of thework 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 all required inspections. Complete drawing on reverse side. n � Signed X_i-- `� �.._._ Title: Sp r .S�zi - l�U/OGIJ" Date: OR MENT USE ONLY Application Accepted by. Date a Pit or Grout Inspection by Date Final Inapection by Date a ' y 4J Additional Comments: Applicant - Return all copies to: San Joaquin County Public health Services Environmental onPermit/Services VI2F©�C5 �r �n '445NSanJoaquin, P 0 Box2009Stkn, CA 95201 INFEO A7�MJO9NT DUE AMOUNT REMITTED CASH RECEIVED BY 1 DATE /may QPERMIT'NO. H 13-24 W44.�IREV.i/n5V �'1 V F � d® �/' D`-.