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• APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. City of Stockton right-of-Wayy in Job Address vicinity of 535 Center Street City Stockton Lot Size/Acreage Owner's Name City of Stockton Address 425 N. El Dorado Street Phona(209) 937-8374 1150 3 - 1150 W. Trenton g -� Ave �" Contractor H-F Drilling Address Oran e, CA �vagi License No,505990 Phone (714)532-61 0 TYPE OF WELL/PUMP: NEW WELL 52 WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 R Industrial O Open Bottom ❑ Manteca Die. of Well Excavation 12 inches Dia. of Well Casing 4 & 5" ❑ Domestic/Private kl Gravel Pack ❑ Tracy Type of Casing_ PVC Specifications 1'1 Public 1'I Other fl Delta Depth of Grout Seal Type of GroutCement I I Irrigaton _Approx. Depth I I Eastern Surface Seal Installed by H-F Drilling Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 futJ Installation will a: Residence_ Commercial_ Other Number of living unite: Number of bedrooms Character of soil to a depth o wt• Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to near Well Foundation Property Line LEACHING LINE ❑ . Ila Length of lines th/size FILTER BED ❑ Distance to nearest: Well Foundation Propertyna� SEEPAGE PA 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 or licensed agent'ssignature cenifies 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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenu- tion laws of California." The applic 9 m/y�st,scall ff /all r q IfI ell 'nspections. mRlete drawing on reverse side. 1 µ Sp ) ��4vruNil� 1 Gb I F /"JTitle: �(0 . CIIZligMIL Date: (/�(; ,� yf�AOpA DDEPPAA_RTMENT USE ONLY 1. Application Accepted by C � �' - ` 1 �� "" _ Date 3 a Area `It or Grout Inspection by Date Final Inspection by Date 'anal Comments: tcant - 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 OA AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO -sto� �coa L�f— 12t,3041 G-