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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL IIEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 29RR, STOCKTON, CA 95201 388 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. t Job Address 6349 Ea.9t Pine City Ln r3 i i Lot'Size/Acreage Owner's Name B&H Towne Etal _ Address Nhon4916_ 1424 - Stockton, CA } Contractor Spectrum Explorat&cbn 2825 Es Myrtle St . License No. _5_122b_8__Phone( 16 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER tt 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 ❑ Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing NI Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing- Specifications ('1 Ptiblic X1 Other n Delta Depth of Grout Seal Type of Grout 111frivation _-.- Approx. Depth D1 Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ g Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth � TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION i I lNo septic 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. 0 Method of Disposal Distance to nearest: Well -"Foundation Property Line LEACHING LINE Ll No. $ Length of lines Total lengthisize FILTER BED n Distance to nearest: Well Founaation Property Line SEEPAGE PITS [ I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl I hereby certity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate 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 followin erti y that a performance of the work for which this permit is issued. I shall employ persons subject to workman's compensa- tion laws of C rnia." The ap ' nt ust call or all r uir inspections. Complete drawing on reverse side. Sig ad X Title. • ite: s 0 EPARTMENT USE ONLY Applic ion Accepted by Data Area Pit or Grout Inspection by � Date rFin� Inspection by 4 LL � Oats Additional Comments: - �'V f1N� Applicant - Return all copies to: San J quin County Public Health Services Environmental Health Permit/Services " 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 i FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8y [r PATE PERMIT'NQ. • EH 13-24(ACV.1/n 51 Is too ,,I g�. ID .� .� Page 13A EH 14.20 :4