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,3. .. y APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BM 2009, STOCKTONI CA 95201 <br /> (209) 468-3447 <br /> (Complete in Triplicate) � <br /> 'Joaquin County for a permit to construct and/or install the work herein described. ThiBan <br /> application i■ made in C=Wliances <br /> Application is hereby made,to Baa . <br /> with San Joaquin County Ordinance No, 51+9 and 1862 and the Rules and Resula <br /> Joaquin County pp��b��iie Health services, 9--d' 200} x 200, <br /> Job Address i <br /> Building ©1, Tracy Army Depo? City Tracy. Lot size/Acreage <br /> Army Corps of Engineers 25600 S: Chrisman Rd. , Bldg. 2fl�phone (209) 832-9908 <br />� Adores: <br /> Owner's Name Tracy, CA 95360-5000 <br /> 52268 (209)465-87I <br /> Contractor <br /> Spectrum Exploration Address <br /> 2825 E. Myrtle St. , StOc && No. <br /> Phone <br /> WeLl Ll <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Q DESTRUCTION © Out XK Moniitorin well CE' <br /> SYSTEM REPAIR ❑ OTHER "rU <br /> PUMP INSTALLATION © -53 (6j ' p15P05A1 FLD.� 5a PROP. LINE <br /> SO SEWER LINES <br /> DISTANCE TO NEAREST: SEPTIC TAN!( 300 t PITS/SUMPS� l <br /> TBA FOUNDATION Sd / AGRICULTURE WELL S� OTHER WELL ("11 $rf <br /> er <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPE l -� Die. of Well Casing <br /> n Industrial ❑emsottom C) Manteca Die. of Well Exe PVc"Schedule 40 specifications <br /> U Domestic/Private �; Pack Type o1 Casing Tracy r Cement Bento its <br /> ❑ Delta Depth of Grout Seal T Pe of Grout <br /> Q Public I'l f)+her Spectrum Exp-Loration stee casin <br /> G Irri tion. Approx. Depth ❑ Eastern Surface Seal Installed by <br /> ,% i grin W TT H.P. <br /> State Work Done_ <br /> Repait WOik one ype of Pump �.�-- Sealing Material i Depth v <br /> Well Destruction © . 'Well Diameter Filler )kterial i Depth <br /> Depthrmitted if pub' sewer is <br /> TYPE OF TIC WORK: INSTAL N 0 REPA DDITION OE5TRUCTION +Nailabkrc e `yin 200 feet.) <br /> stallation will : Residence Commerc• Y._. Other <br /> Number of g units: Number of ooms <br /> Water table pth <br /> Charec of sow to a de of 3 test: No. Co mments <br /> SEP TANK. C) Type/ Capacity —1 <br /> Me od of Ditlpo <br /> P G. TREATME LT. 0 <br /> istance to ne t: Well Foundation Pro Line { <br /> LE iNG LINE ❑ No. ength of lines Tot ength/tis 1� <br /> FILTER BED ❑ tante to nearest, Well <br /> Foundation Property no_ <br /> SE GE PITS I I Depth Sire Number <br /> SUMPS Ll Oista to nearest: W Fou tion Property Li <br /> DISPOSAL NDS ❑ <br /> d that the work will be done in accordance with San Joaquin county ordinances, state laws <br /> I hereby certify that l have prepared this application an . and <br /> rules and regulations of the Ssn:Joaquim County <br /> Home owner or licensed agent's sip lure certifies the following; "I certify that in the performance of the work for which this permit is issued. ! shall <br /> na not <br /> employ any person in such ma as to.become subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature <br /> certifra thr foIi wing: "I certifV111 _ the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa <br /> tion itsws of i orn ' <br /> The appkca st w for all ui�ed' spactions. Complete drawing on reverse side. 4/6/92 <br /> Signed <br /> ! ,—L Title: Project Geologist pate: <br /> FOR DEPARTMENT USE ONLY <br /> Date �U 9-z' Area <br /> Application Acc tsd4 <br /> /►lL r�i�— ,7j/1 . `t -15 R.y -fit- Oates <br /> Plt or Gr ut Inspect' by e/ Final inspection by <br /> Additional Common <br /> Applicant - Return all copies o: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES "l <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> CK A RECEIVED BY GATE � <br /> PERMIT'NO. <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED �rCCASH <br /> . Eft 13-24 IIIEV. .51 �— }--�" lh6 l <br /> EH A-25 C !!! <br />