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APPLICATION ,WWI , SAN.JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION RECEIVED 445 N SAN JOAQUIN,PHONE(209)469-3420 P O BOX 388, STOCKTON,CA 95201-0388 POR 12 50151 PERMIT E%PIRES 1 YEAR FROM DATE ISSIIEDSAN JOAQLAN C7;i-tNTY JBL1C HEAL i H SEP% e!CES (Complete in Triplicate) ENVIRONMENTAL HEALTH DIVISION 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. 145 South Sutler Street Stockton Lot Size/Acreage N 1.5 Job Address City San Joaquin County 222 East Weber, Rm 678 Owner's Name �rdn1 tnl Projects Address Stockton CA 95909 Phone - 2081 2825 E. Myrtle St. Contractor Spartrum R-rp1orntion Address S o kion. CA 95205 License No. 512268 PhoneZ09-465-8712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION CA Out of Service Well ❑ PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK )t 50 SEWER LINES > 50 DISPOSAL FLD. > 50 PROP. LINE),10 (.FP-Pt) FOUNDATION -->--2-Q— AGRICULTURE WELL 50 OTHER WELL 50 PITS/SUMPS (=5D INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L) Industrial 15-0p;-- -Bottom ❑ Manteca Dia. of Well Excavation - Dia . of Wall Casing 4-inch [I Domestic/Private &1 Gravel Pack Ll Tracy Type of Casing_ PVC Specifications15 r Screens I1 Public 1-1 Other n Delta Depth of Grout Seal 21 r_ ' 28T Type of Grout Bent Cmt I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Driller Repair Work Done U Type of Pump M.P. State Work Done_ Well Destruction 13 Well Diameter 4-inch Sealing Material i Depth 59 Bentonit/Cement grout Depth _ Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 sail to a depth of 3 feat: 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 Cl No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nsanst: Well Foundation Property Lina DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iowa, 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: "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 t cell 1 I ui d/in'spections. Complete drawing on reverse side. Signed x Title: -- Registered Geologist Date: 3/29/95 FOR DEPARTMENT USE ONLY Application Accepted by Date �. Area Ph or Grout Inspection by,�'1-MIR 1 1� I,aN,I Date r Final Inspection by t"V"'-WN' NW✓ Date Additional V Comments: i k td r cn&-1 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 95 20 1-03 88 FEE INFO AMOUNT DUE AMOUNT REMITTED CAKS,, RECEIVED BY DATE PERMIT NO. . EH,I.N IaEV.rin,l B) 4Go • R EM 1421