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- i ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES AppENDIX C ENVIRONMENTAL HEALTH DIV 445 N SAN JOAQUIN, PHONE (209 468-3 # I t l v I P O BOX 2009, STOCgTON, CA 95201 PERMIT RES 1 YEAR FROM D E ISSUED Jb7 (Complete in Tripllca ) # alb Application in hereby made to San Joaquin County for a permit to construct an o i Th application is made in Compliance with San Joaquin County ordinance So 549 a 1862 and the Rules and Regulati s SSa r. Joaquin County Public Health Services. -- - — - Job Address Caltrans/1603 South "B" Street City Stockton Lot Size/Acreage owner a NCaltrans- _ Address 1976 E. Charter Way, Stockton Phone - 01Z opartipent of Transportation) W. Sacramento Contractor Westex AddressP•O- BOX 1664, CA 95691. License No C-57 S521913Phone)216) 373-11J 8 TYPE OF WELL/PUMP NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION 3 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well )a 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 C7 Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing n Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing Specifications 14 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout ' i I Irrigation —Approx depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H P State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIRIADDITION I l DESTRUCTION i� s system permitted d public sewer is ii�_/X 14 ��+vrilhin 200 lest I Installation wnll verve Residence— Commercial— Other RECEIVED Number of living units Number of bedrooms Ay 3 Character of said to a depth of 3 feet Wets tablo depth SEPTIC TANK ❑ Type/Mfg Capacity �=tss rtmants PKG TRf.ATAAENT PLT ❑ pllLlC HA�1�� I �osal Distance to nearest Well Founded NTNTAky Lino LEACHING LINE Cl No 8 Length of Imes Total length/size ' ' FILTER BED ❑ Distance to nearest Weil Founcation Property Line SEEPAGE PITS It Depth Size Number SUMPS LI Distance to newest Well Foundation _ Prooarty Lino DISPOSAL PONDS ❑ I hereby certify that i have prepared this applicanon 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 cer firms the following I certify that in the performance of tho work for which this perrtut 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 candies the following "I certify that in the ptirtormanco of tho work for which this permit is issued I shall employ persons subject to workman s Compensa non laws of California " The applicant m t all or all ro uin Complets drawing on reverse aide ) Signed X dlg>►-.f Title Swti - L Date LkI �9 OR DEPARTMENT USE ONLY ' Application Acceptod by Data Aron Pit or Grout Inspection byX Dats Final Inspection by Date Additional Commanta _ 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 INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED 9Y DATE PERMIT NO .sem � et p Page 13 ' EK 13.24(REV 1.,gp1 /r} zfJ� fm A 20 K..Y/