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SAN O QUIN COUNTY PUBLIC HEALTH S14VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 %^ • ". 1 PERMIT EXPIRES .1 YEAR FRAM DATE ISSUED ORIGINAL 1 (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein describ6dZ .-This application Is made in compliance with San Joaquin County Ordintulce No. 549 and 1862 and the Rakes and Regulations of'San Joaquin County Public Health Services. Job Address — — ?QQ0 STIMsnN R ,city STOCKTON Lot Size/Acreage Owner's Name CA. ARM Address 9800 GOETHE�RD SACTO,CA 95827 Phone 916854-3606 a>< -1 4 p S_ S�"" �c.t1*�%4kW 63 $7 .570-2,37-Y Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out or Service Weil ❑ � GEOPROBE BORINGS PUMP INSTALLATION C1SYSTEM REPAIR ❑ OTHER IN Monitoring well ❑ ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES VARIES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL VARIES PITS/SUMPS ,T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing {..l Domestic/Private Li Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public (l Other n Delta Depth of Grout Seal Type of Grout-CEMENT W/ I I ImElation _Approx. Depth I I Eastern Surface Soul Installed by 5% BENTUNIT-E Repair Work Done LJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material I- Depth 5-25 FFFT- SOIL Depth 5_25 FFFT Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION t I INo 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 sod to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity filo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal l NIA Distance to nearest: Well Foundation Property tine LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line ' NIA SEEPAGE PITS NIA I I Depth Sue Number SUMPS Cl Distance to nearest: Woo Foundation Property Line 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 taws, and rules and regutations of the San Joaquin County, Horne owner or licensed agant's signature certifies the fokwing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson in such manner as to become subject to workmen's compensation laws of California."Contractors 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 compansa•: C Hort laws of California." I The applicant must cAll for squired inspections. Complete drawing on reverse side. Sigma (r F'C Title: SENIOR GEOLOGIST Date: -�5 !LCIU FOR DEPARTMENT USE ONLY Application Accepted by Date !�a Uv Area Pk or Grout Inspection by Date Final Inspection by ate Additional Comments: ve Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'No. INFO 1�+? SH /1 Page ,�3t E1413.2191PIEY.linsr L 1/10CA /(� l i En 11 719 ( f