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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t. (Complete in Triplicate) ; Edo - B,E„t.T � ,.f ►Lc��f:. p1?-7-- 7.3 Application is hereby made to S"!Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Co i s. "9y_-TU°l#PVft %zrvi .5 ' E. of Gettysburg Job Address Place & 136 ' 81. of Ben. Holt Dr. ci,y Stockton Lot Size/Acreage County of San Joaquin Owner's Nam. Dept . Of Public WorkSlddress 181.0 E. Hazel tan Dr- Stocktr%one _468-3000 Diablo Pump Cod. 3620 Chestnut Ave . 639090 510-687-9 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLA EMENT ❑ DESTRUCTION [Xput of Service Well t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER•WELL PITS/SUMPS INTENDED USE ITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G C] Industrial Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing Cl Domestic/Private 6-Gravel Pack-- ❑ Tracy. ---Type-of-Casing.,.. ----- - --Specifications V1 Public l I Other fl Delta ;Depth of Grout Seal { Type of Grout w I I Irrigation V=Approx. Depth 11-Eastern --- (-Surface•Seal-Instalied aby Repair Work Done U Type of Pump H.P. i #State Work Done — Well Destruction 1_4_'_78_"1 inE iYng•;Mnterii14 Depth 4. S 941 =p-at-cement L9` Well Diameter � tfa-2�� s Depth 254' Filler Material i�Depth TYPE OF SEPTICrWORK: 'NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will'serve: Residence :tCommercial_.—.. Other , j � V-0 Number of living units:*r Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTICTANK. Y(i J0t Type/Mfg Capacity No. Compartments PKG. TREATMENT P,LT.,Ej� Method of Disposal `�} ! Distance to nearest: Well Foundation . Property Line f LEACHING LINE 0 No. & Length of tines Total length/size Q) FILTER BED {_]? Distance to nearest: Well Foundation; Property Line SEEPAGE PITS l I; Depth Size T�Number _ SUMPS r Ll' Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS ❑i I Q 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, ander 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 ncm employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature, r 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 trust c II a r ire in Ions. Complete drawing on reverse side. e Title: contractor/owner July 15, 1992 _ l Signed X Date: _ .d FO DEPARTMENT USE ONLY ! Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by to ��rl Z Additional Comments: I Applicant - Return all copies to: San Joaquin C my Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE h INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PE`R]MIT'NO. [[�� . EH13.24iREV.iin5iWO (0p,�D �,,,,11`/ QI^�� EH 14.2. YJ r