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APPLICATION FOR PERMIT <br /> S4WJOAQUIN COUNTY PUBLIC HEALThmeERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. . PHONE (209)46$-3420 <br /> P O BOX 2009. STOCKTON, CA 95201 <br /> RIMNI_T_ EXPIRES 1 Y aR„ gR031 DATE ISAURn <br /> (Complete in Triplicate) <br /> Application is hereby made <br /> application to Pude in a to "A Joaquin County for A permit to construct and/or iaatr]_L the work herein described. This <br /> Joaquin County Public health t1hienc$erve withicaaS` j Jorquia County Ordinance No, 549 and 1862 AM the Mutes and Regulations of San <br /> Job Address 345 North San Joaquin city Stockton Lot size/Acreage 100ft x 330 <br /> Pacific Bell 2 North Second Street. #675 <br /> Owner'sName Addreis San Jose. CA 95713 Phone 408-491-4605 <br /> Spectrum Exploration 2825 £=..Myrtle <br /> Contratior Addreis Sf�ckton, ' U ,License No, 512268 ,,,�0ne z09-465-8712 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or Service Weil ❑ <br /> PUMP INSTALLATION ❑ SYSTEM AEPAIA ❑ OTHER ❑ Monitoring (Jell %K <br /> DISTANCE TO NEAREST: SEPTIC TANK >500 ft SEWER LINES 5-10 ft DISPOSAL FLd7.L,00ftpgOP. LINE 5-10 ft <br /> FOUNDATION __1_0f t AGRICULTURE WELL�500ft OTHEA WELL2 0.3 00 PITS/SUMPS 71500 ft <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall 6reavalion Dia, of Well Casing " <br /> C1 Domestic/private IN Gravel Peck ❑ Tracy Type of Casing sch 40 PVC <br /> Specifications <br /> VI Public Cl Other n Delta Depth of Grout Seal 30-40 ftTyps of Grout <br /> aft bentonit <br /> _ <br /> I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by IT Corporagorporat ion neat Cement <br /> Repair Work Done LJ Type of Pump H.P- State Work Doni_ surface. <br /> Well Destruction ❑ Well Diameter Sealing Material L Depth <br /> Depth Tiller Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> Installation will serve: Residence._ Commercial_ Other available within 200 fbet.l <br /> Number of living units: Number of bedroom! <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT.❑ r� <br /> Method of Disposal v`1 <br /> Distance to nearest: Well Foundation Property Line r <br /> LEACHING LINE ❑ No. & Length of lines Total length/ii:6 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS L1 Distance to near6st: W611 Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> 1 hereby comity that I have prepared this application and that thb work will be done in accordance with San Joaquin county ordinances, !tate laws, and <br /> rules and regul6116ne of the San Joaquin County r' <br /> Home owner or lin in such <br /> man er as to b ee becefeome <br /> the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any pMabn in such manner as to bacorM eubi6ct to workmbn's compensation laws of California,"Contractor's hiring or subcontracting signature <br /> eertlfist the following: "I certify that in the performance 01 the work for which this permit is issued,I the"employ 1 <br /> tion laws of Cali ia." y persons subject to workman's compansa• y <br /> The applies 1 N pact-' plate drawing on reverse side, <br /> Signed Title; Pro ect Manager 11/25/91 ,Q <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by DateC <br /> Area <br /> Pit of Grout Inspection by Date ,, _ Final Inspection by <br /> Date <br /> Additional Comments: <br /> Applicant - Return all copisa to: San Joaquin County public Health <br /> Services. zaviroamentiLl Health Peradt/Services <br /> 1601 z. 8a161ton Ave., P 0 Box 2009, Stockton, CA 95201 (( <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED by DATE PERMIT NO, <br /> . Ex 13-24 1"Ev,irnel <br /> IM 74101 <br />