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! APPLICATION SAN JO-QUIN COUNTY PUBLIC HEALTH S '1ICES + 4 I E VV I RONMENTAL HEALTH DIVISION pa YMeNT 45�,,N SAN JOAQUIN, PHONE (209)468-3420 ;; R'aCEI P O BOX 2009, STOCKTON, CA 95201 JA N 13�� PERMIT EXPIRES 1-YEAR FROM DATE ISSUED i�93 SpN JOq (Complete in Triplicate) EI11VlRpLME�q�rHS�RVCES j Application is hereby made to San Joaquin County for a permit to construct and/or ins tal] the work herein described. �R/ 4f11 application is made in cottrpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of�Ban� Joaquin County Public Health Services. y' Job Address Stockton Airport - 2000 Stimson Road City Stockton tot Size/Acreage Owner's NamoOffice Of the State Architt i_fe,s 400 P Street, 5th Floor, SacramAqXq 916--323-5819 I Contractor Westex Drilling Address P.O. Box 1664, W. Sacrk%VQ, (� 0 552198 Phone 916-373-111 TYPE OF WELL/PUMP- 3 NEW WELL g WELL REPLACEMENT C1 DESTRUCTION 0 Out of Service S1e11 ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring Nell ❑ y DISTANCE TO NEAREST: SEPTIC TANK 7 5o1 SEWER LINES 7 501 DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS INTENDED USE TYPE OF WELL i' PROBLEM AREA CONSTRUCTION SPECIFICATIONS C industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10Dia. of Well Casing 411 (X Domestic/Private {XGravel Pack 0 Tracy Type of Casing- PVC Specifications ; Cl Public Cl Other it Delta Depth of Grout Seal 501 Type of Groutcement--bento ite I i Irrigation —Approx. Depth I I Eastern Surface Soul Installed by Westex Drilling Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth CiTYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Q Installation will serve: Residence_ Commercial _ Other Number of living units;" - Number of bedroomsLu Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0' Type/Mfg-. -1 Capacity No."Compartments PKG. TREATMENT PLT. ❑ 1 Method of.Disposal Distance to nearest' Well " Foundation Property Line 0 LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED 0 Distance to nearest Well Foundation - Property Line i # I SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest Well Foundation Property Line 5 DISPOSAL PONDS ❑ 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, and rules and regulations of the San Joaquin County 11' 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 sub)ect to workmen's compensation taws of California." Contractor's hiring or sub-contracting signature = ., cartifies 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 must call for all required inspections. Complete drawing on reverse side. Signed ? C . Title: sa.. 4 b _ Fie oc Date OR MENT USE ONLY Application Accepted by Date a Pit or Grout inspection by Date Final Inspection b Dats r f Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �,�t►o � E4irOStai Health Permit/Services 1 9,455 N San aa Joaquin, P O Box 2009, Stkn, CA 95201FEE V / lf�• �/�!{J I INFO AMOUNT DUE AMOUNT REMITTED CAST RECEIVED BY DATE PERMIT"ND. �,=4.20 II,EV.,,h51 S'y 00 �e0 �'�� 1 ��