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APPLICATION • 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Area 1 APN 114-14.0-18 Job Address Brookside Development City Stockton Lot Size/Acreage owner', Name Grupe Development Address 2024 E Charter Way Phone 473-61 Contractor Clark Well Address 2024 E Charter Wa. License No. 371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION * Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O 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 f� Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing e CI Domestic/Private O Gravel Pack ❑ Tracy Type of Casing- Specifications I.) Public 1.1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ 4 Well Destruction ❑ Well Diameter Sealing Material & Depth E Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPA!R/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms r r Character of soil to a depth of 3 feet: Water table depth N( SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines l g 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 regtions of the San Joaquin County Home owner or icensad 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 r n in such/Manner as to ome subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the f II wing: "I certify t at in to a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of i ornla.' The applica sl c lllto 1 it d s 'on . Complete drawing on reverse side. Signed X Title: Sec-Tres Date: 4 Dec 91 FOR DEPARTMENT USE ONLY Application Accepted by 0.— Date Area Pit or Grout Inspection by Date Final Inspection by Date �Z Additional Comments: 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 ��J (�•D FEE AMOUNT DUE AMOUNTREMITTED CK RECEIVED BY INFO CASH GATE PERMIT'NO. / ��JA / q EH 1�•2e 7.21(REV.rix5r EH 1 —/// — l� r(� C It/-