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. � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ; 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT MWIRES 1 YEAR FROM DATE ISSUED { 7 (Complete in Triplicate) nq7- q-Inw 7 f G-c r✓Goc a►J' # Applicatio is hereby made to Sin Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin cou y yblleLl t t'viae. t E. of Gettysburg Stockton Job Address Place & 3 80 1 'N.. of Ben Holt Dr.. City Lot Size/Acreage County of San Joaquin Owner's Name Dept. of Pub iC WorkSaddress 1810 E. Hazelton,Stockton Phone —4-6-&-3000 3620 Chestnut Ave. 639090 510-687-9 Contractor Diablo Pump Co. Address License No. Phone Wt4 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL CEMENT ❑ DESTRUCTION Mout of Service Well IN PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well t. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications { i'1 Public 1-1 Other I n Delta Depth of Grout Seal Type of Grout # i i Irrigation —Approx. Depth 13 Eastern Surface Seal installed by Repair Work Done U Type of Pump H.P. State Work Done_ ' Well Destruction t Well Diameter 1411&12't Sealing Material & Depth 4- 51 t o 1 6 0 1 n e s t Cement Depth 276 ' ( 100m) Filler Material & Depth Vi[leo shnws fill to 100 ft . TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is # i available within 200 feet./ # Installation will serve: Residence __ Commercial— Other F Number of living units: Number of bedrooms F Character of soil to a depth of 3 fee17 Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal t Distance to nearest: Well Foundation Property Line j 1 LEACHING LINE ❑ No. & Length of lines Total langth/size FILTER BED n Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth f Size Number SUMPS LI Distance to nearest: Well Foundation Property Line t 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 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 mus o all equir spections. Complete drawing on reverse side. _ Signed Title: contractor/owner Date: allly 1515 , 1992 F R Q ARTINENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ate 2 r � Additional Comments: r Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE f III LNFO AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BY DATrE,�j QPERMIT'�NNO. . EH c3.21IREV.t1n�i � f',fr 212 - ~ rZ A. =` t EH 1�•2ll l��