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APPLICATION • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,PHONE(209)469-3420 P 0 BOX 388, STOCKTON,CA 95201-0388 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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 2025 WEST HAZELTON City STOCKTON Lot Size/Acreage 7 Owner's Name I-0UNCO, INC Address 401 E. OCEAN BLVD., SUITE 501 Phone 510-603-7924 Contractor NONE Address N/A License No. N/A Phone N/A TYPE OF WELL/PUMP: NEW WELL O - WELL REPLACEMENT ❑ 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 f]y Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l Public BORjNGSATD-All ff1 f1 Delta Depth of Grout Seal Type of Grout I I Imgauon _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 ''Nn Depth _ Filler Material a Depth BACKFILL YIITH CUTTINGS TYPE OF SEPTIC WORK. NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I Ileo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living unite _ Number of bedrooms Character of wit to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 77 Distance to nearest. Well Foundation Property Line [r LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �y SEEPAGE PITS 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'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 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ perwns subject to workman's compensa- tion laws of California." The applicant st c I-le all squired inspections. Complete drawing on reverse side. Signed Title: GEOLOGIST Data: 6/26/95 FOR DEPARTMENT USE ONLY _ h / Application Accepted by Dote y✓�� Area Pit or Grout Inspection by DJare�J��'��r� �Finall Inspection byA ata Additional Comments: "t'`• wt/"/ '[l l/QQIfI• �NrA�r 'o11W/cY/1 �i1L01(Yy1LJdn ""'su'�^*`� r t✓- Applicant - Return all copies to: San Joaquin County Public H alth&m1ecs Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 ea^ a NFEE FO AMOUNT DUE AMOUNT REMITTED CK RE EIVED BY DATE PERMIT NO. 01., �9•� a N EH 111-24IREV.trnel •/ t/� IO 1� ��