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0! APPLICATION 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, 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. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4480 Brookside Clty Stockton Lot Size/Acreage Owner's Name Grupe Development Address 2271 W March Lane Phone 473-615 Clark Well2024 E Charter Way License No37156o Phone 462-7676 Contractor Address . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION W Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER C Monitoring Well 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 Ll Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing [] Domestic/Private ❑ Gravel Pack C Tracy Type of Casing_ Specifications I"I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout-- ii routII Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U 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 I I INo septic system permitted if public sewer is available within 200 feet.) r v Installation will serve: Residence _ Commercial _ Other t Number of living units: Number of bedrooms Character of soil to i 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 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 San Joaquin County Home owner 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 on in such manner as to become a ject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the oil wing: "I c ify that in a rfor ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of lifornia." The applic ust c 11 for r ( n Ctio Complete drawing on reverse side. Signed X Title: Sec-Tres Date: 4 Dec 91 FOR DEPARTMENT USE ONLY Application Accepted by Date ( Area Pit or Grout Inspection by f -.�/� Date i-1-1'2-�i �!Final Inspection by Additional Comments: 67e � 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 LU �j FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH q EH 13.24(REV.I/x 5) - L � EH 14.26