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APPLICATION FOR PERMIT k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION _ � �� f 445 N SAN JOAQUIN, PHONE (209)468-3420 r 2 09 STOCKTON ' P O BOX 0 , CA 95201 PERMIT EXPIRES I YEAR ROM D TISSRW- (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby merle to San'Joaquin County for a permit to construct and/or install the vorkttibf>rG1N1USEW0 e application is made in compliance 4ith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of Sand Joaquin County Public Health Services. " 5,15 :N v;T. Drive C;ty Stockton Lot Size/Acreageza xOX.6 acrPS Parcel south of 6- Job Address 511 N.3rookhurst' Street -� She11� Oil Cots ariY _ Address Anaheim,CA. 92803 Phone71�+ 520-3389 rw er s Name i7 Harding Lawson Associates 200 Rush Landin'g Road,Novato,CA.537366 `(415)892 08 ((`)) West �Iazmat Drilling Address 3233Fitzgerald,Rancho Co-c4pg@ rio. C57=554'979phone 9 -008' 727 ' 6tfn�raclor TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 1) OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FCD. - PROP. LINE apprCXllTlate5 ATION AGRICULTURE WELL OTHER WELL 60 ft_`PITS/SUMPS " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LE 1nCheS C7 Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation n S Dia. of Well Casing [I Domestic/Private CX Gravel Pack ❑ Tracy Type of Casing_ PVC Specifications ` I'] Public f-3 Other I� fl Delta Depth of Grout Seal a rOx. 8ft. Type of GroutCeC7Cnt-beLltO I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump 1 H.P. State Wgrk Done r Well Destruction ❑ Well Diameter[l 1nC 1eS Sealing Material i.Aepthcement"bent--1 to ai7prDX. t. Depthapp: qx. 30ft. Filler Material & Depthlean L"Ie sand apyraX. 8-30 ft. TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I hails Attic system m permitted if public sewer is Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet:'. Water table depth SEPTIC TANK. ❑ Typs/Mfg Capacity No. Compartments i Method of Disposal (f� I 'S PKG. TREATMENT PLT. © I 4 Distance to nearest: Well Foundation Property Line LEACHING LINE 0No. 8 Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line sf SEEPAGE PITS I I Depth !f Size Number - SUMPS f l..flistanca-to nearest: WeH y — = foundation-------- �Propsrty Lina— ^` DISPOSAL PONDS ❑ r 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 Count Home owner or licensed agent's signature ce : "I certify that in the performance of the work for which this permit is issued, i shall not employ any parson in such manner as to L man's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in t 6110} wigsk for which this permit is issued, I shall employ persons subject to workman's compenaa tion laws of California." C4c The applicant must call or alI required s berm,C I to ra ing on reverse side. Senior Hydrogeologist Date: 8-2692 Signed EPARTMENT USE ONLY FOF CALIF Date f Area "�' Wkclq Application Accepted by {' Pit or Grout inspection by Date Final Inspection by a Air Data 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 FEECK AMOUNT DUE, AMOUNT REMITTED CASH I RECEIVED BY DATE PERMIT NO. INFO II . . EH 13.24(BEV.1 i"e) X02 cel r��Z r'�'S �i� . EK t�•7e