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• APPLICATION p y+ SAN JOAQUIN COUNTY PUBLIC HEALTH SE �y SR � tt ENVIRONMENTAL HEALTH DIVISIO Ji r 445 N SAN JOAQUIN, PHONE(209)469-3 2FA/� u P 0 BOX 388, STOCKTON,CA 95201-03 8 2F fill fT PERMIT EXPIRES 1 YEAR FROM DATE (Complete in Triplicate) Application is heieby'madelR$an-Jbagnin County for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Development Tide Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Jab Address 3301 Navonne Cay Stockton—F. Lot Size/Acre e IQ ACTS Owner's Name Q.S. Intec, Inc. Address 3301 N. Navonne RnAd Phone _1 o77 3241 Fitzgerald Rd. Ste 2 Contractor Turner Exploration Address Rancho, Cordova 95742 License No. LD2770Phone9l r—R5?-754 > TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public F1 Other M Delta Depth of Grout Seal Type of Grout I I Irnganon _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H . State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth OIL BORINGS(5) Depths Fr Piller Material i Depth 49 l9 n ni /C TnPn out TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No sepbc system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to a 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. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line,_, SEEPAGE PITS II Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby canify 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 peiformance 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 compensa tion laws of California." The applicant ust a lore ract r ins actions. mpate drawing on reverse side. Signed Title: GEOLOGIST Date: 5/2/95 FOR DEPARTMENT USE ONLY �l Application Accepted by Date �� 4 Area Ph. or Grout Inspection b ✓ / V Data ' �� Final Inspection by //( Date i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 m F4 FEE AMOUNT DUE AMOUNT REMITTED CK INFO SH ECEIVED BY 1DATE PERMIT NO. -Ts.m laev. ,.sl rUU