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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES TAL HEALTH DIVISION PAYMENT SAN OENVIN COUNTY- HEALTH�D i�O�AVIE , PHONE (2095201-342CPECEiV ED 1991 SPECIAL PER '�T EXPIRES 1 YEAR FROM DATE ISS 1991 JOAQC,IN COt1fV;-y (Complete in Triplicate) p�. FAQ r„ �t�p'I �.ti, n SRVIC�g Application is hereby made to San Joaquin County for a permit to construct and/or insta]1:ICtt�� rrl�Tf z}d€AL(1t }/�e This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulaiidd� San Joaquin County Public Health Services. Job Address 121 S. Center Street City Stockton Lot Size/Acreage 1.5 Acre Owner's Name Greyhound Lines, Inc. Address 901 Main Street, Ste. 2425, Phone 214 744-6511 Dallas, TX Contractor __EDectrum Exploration Address 2825 East Myrtle St. License No. 512768 Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYST IR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINESt'1 ' DISPOSAL FLD. NA PROP. LINE 20' FOUNDATION —±-O.L— AGRICULTURE WEL OTHER WELL NA PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation__1 0-12" Oia. of Well Casing " O Domestic/Private CA Gravel Pack ❑ Tracy Type of Casing SCh. 40 PVC Specifications i'1 Public tD Other fl Delta Depth of Grout Seat bentonite Type of Grout Cement/bent iit I I Irrigation 4a Approx. Depth ( I Eastern Surface Seal Installed by _Spectrum Exploration Repair Work Done U Type of Pump NA H.P. NA State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth Fitler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is t� available within 200 feet.) V t Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms (� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal V Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O '^ 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:"1 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 must Fall foruired 'nspections. Complete drawing on reverse side. Signed X h- Title: Hydrogeologist Date: 8/19/91 FOR DEPARTMENT USE ONLY A / Application Accepted by pp Date �` / Area �,31 91 Pit or Grout Inspection by Date — W Final naneltion by _ -'�'" Date ! A Additional Comments: QWC UIN i -PUBLIC HEALTH SERVICES A iZt - Return all pies to: San Joquin oust/ blic Health ENVIRONMENTAL HEALTH DIVISION I,�� / � Services, vironmental Health Permit/Services (� p ��►�/d �7 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, cS't_52&'CIAL PERlYiJC -00 LFE INFO A GLINT DUE AMOUNT REMITTED CASH RECEIV D BY DATE CX i PERMIT'N0. �r • EH 13.20 IAEV.1ins) „rteEH7t•2e V ( l