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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONYSNTAL HEALTH DIVISION /�I �' ))�J <br /> 445 N SAN JOAQIIIN, PHONE (209)468-3420 ��v/// <br /> • P 0 BOX 2009, STOCKTON, CA 95201 , (a <br /> PERMIT EX-PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or Install the vork herein descri KeEl This <br /> Application is made in compliance with San Joaquin County Ordinaries nce No. 549 and 1862 and the Rules rend Regulations o�7-San <br /> Joaquin County Public Health Ser-vices. <br /> Job Address _ ?OOO STIM4nN Rn.City STOCKTON Int size/Acreage <br /> Owner's Name CA. ARMY NATIONAI GIJARn Address 9800 GOETHE RD SACTn A 95897 phone 916 854-36 <br /> �cis`e"� 631o3f 7 570 -237- <br /> License Contractor Address License No. <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 <br /> GEOPROBE BORINGS PUMP INSTALLATION ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> SYSTEM REPAIR ❑ OTHER Monitoring VeI ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES VARIES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL VARIES PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Spec of Well Casing <br /> Type of Casing_ Specifications_ <br /> I'1 Public Il Other (1 Delta Depth of Grout Seal <br /> I I Irr aton Type of Grout <br /> Approx. C:FMENT U// <br /> b —AD . Depth 1 I Eastern Surface Seel Installed by 5°/ RF ITn <br /> Repair Work Owe U NITF Type of Pump H.P. State Work Owe _ <br /> WallDestruction O Well Diameter <br /> SOIL Sealing Material L Depth 5-25 FEET <br /> Depth —5-95 FFFT Filler Material i Depth - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public rower is <br /> available within 200 fast.)Installatlon will serve: Residence_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character Of moi to•depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT.E) Capacity No. Compartments <br /> N/A Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of tines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> N/A Property Line <br /> SEEPAGE PITS N/A It Depth _Si,, Number <br /> SUMPS LI Distance to newest: W44 Foundation <br /> DISPOSAL PONOS ❑ Property Lure <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws <br /> rules and regulations of the San Joaquin County , and <br /> Home owner Of licensed agent's signature certifies the following: ^I certify that in the performance of the work for which this permit is issued, I shall rot <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compansa. <br /> tion laws or California." <br /> The applicant must <br /> 0 for <br /> uired inspections. Complete drawing on reverse sills. <br /> Signed _Z:Z;' i—C' :WF - Tiles: SENIOR GEOLOGIST Data: 3 /AU <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data '? —/6) ad <br /> Area <br /> Pit or Grout Inspection by Date <br /> Fi <br />� �7p nal Inspection by Data dhksnal Comments: — LO [4� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> Ell!! <br /> CASH RECEIVED BY DATE <br /> pFRM1TNO <br /> ' . <br /> EH 1 Yea laEv.Einar �. ' Page 13� <br /> EH im 2e <br />