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i s APPLICATION FOR PERMIT "1( 3E T Ua ' ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �" 2 1992 P O BOX 2009, STOC%TON, CA 95201 ,f�,k0(JIt'J COUNTY (209) 468--3447 ;' ; ° .;' ,.41--.% ."i+15 P1!lCF PERMIT E%2IRE81 YEAR I�ROII- DATE ISSULI] b``O�i $ORTi t$ S B-3 (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application io made in comWliancekvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. Approximately t Job Address 24 S6: Hunter Street City Stockton Lot Size/Acreage : ---1,- .'5 Acz•es :1 Owner's Name San Joaquin 'Co . Address 222 E. Weber St . , Room 675 Phone 209-468-3252 Spectrum ' Contractor Exploration Address 2825 Myrtle 5t . License No. Phone 209-465-8712 TYPE OF WELL/PUMP" NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER itoring ti1e11 �Bo r�cWi I DISTANCE TO NEAREST: SEPTIC TANK 0 SEWER LINES ppr' 55' DISPOSAL FLU.+150'PROP. LINE �r• 10' FOUNDATION 3-6 AGRICULTURE WELL f150 ' OTHER WELL }150 ' PITS/SUMPS +150 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom © Manteca Ois. of Well Exc tion Dia. of Well Casing U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casin �g Specifications ID Public ("I Other ❑ Delta Depth of Gro Seal -Type of Grout Neat Cemen Ci Irrigation Approx. Depth 0 Eastern Surface Seal Installed by - � Bentonite Slurry Repair Work Done v Type of Pump .P. State Work Done_ Wall Destruction ❑ Well Diameter ori sling Material i Depth Neat Cement�Bentr�.Dite Slurry 4 Soil Sampling Depth /5- ~2 Iler Material 4 Depth Same TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION L"f DESTRUCTION ID INo septic system permitted if public sewer is available within 200 fee t.I Installation will serve: -Residence—r Commercial�rt Other (� Number of living units: Number of bedrooms Character of $oil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I I Depth I Sire Number SUMPS LI Distance tc nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1.1 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 Home owner or licensed agent's signature certifies the following; "t 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 the in the dormance of the work for which this permit is issued, I shati employ persons subject to workman's compensa-. ' tlon laws of Ifor is," The applicant ust call for I e aired in ons. plate drawing Signed on averse side;Title: Date: r / I FOR DEPARTMENT USE ONLY '1c� Dp ��! Application Accepted byAL L aZ:L� Date � 'T�Z Area o S ?-3 Pit or Grout Inspection by Date [!�G�4 Z Fi,.I lnspection by _ S ! �.. Date 1(16 v Additional Comments: S✓�C-v c c. .- Z "rJsc� .r c. �e Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .ENVIRONMENTAL, HEALTH DIVISION PERMIT/SERVICES i445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 INFO AMOUNT DUE AMOUNT REMITTED K ACCEIVED BY p TE PERNtIT"NO, . EH I3-24 IREV.i/n SI , EH a-2e