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-- JOAQUIN COUNTY PUBLIC HEALI&SERVICES As -- <br /> ENVIRONMENTAL HEALTH DIV ON <br /> 1601 P 0 BOX 2009, STOCKTON, CAAZELTON AVE. , PHONE 0 —3420 <br /> 95201 r � VZD <br /> SL� ' Q <br /> REEMIT (EXPIRES I YEARin FROM DAT) ISS 3 IOAQ6,IA� rl;ldty <br /> rk=441EVTA y�r r{ <br /> San Joaquin County for n permit to construct and/or install the work herein descr-flee : This <br /> Application Is hereby made to S <br /> application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations cf San <br /> Joaquin County Public Health Services. <br /> Job Address - 150_ N. Sinclair Avenup cityStockton Lot Size/Acreage 30+ Acres <br /> 66202 <br /> Owner's NameMa Cooline Tower qi Address 5800 Foxri Agp T1r Mission KS Phone 913 362-181 <br /> 85284 <br /> Contractor Layne Environmental Address9002 S. Hardy TaMp2_,AZ License No. 60OL69 Phone(609) 496-65' <br /> TYPE OF CM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ` OTHER Z Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PR�LINE fs <br /> (See Figure 1 ) FOUNDATION AGRICULTURE WELL OTHER WELL PITSfSUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (See Figures 1 and 2) <br /> C1. Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dla. of Well Casing <br /> FI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'I Public I.7 Other fT Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I INo seplic system permitted if public sewer is <br /> Installation will sena: Residence_ Commercial_ Other available within 200 feet.) <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Wall Foundation <br /> DISPOSAL PONDS ❑ Property Llne <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state laws, and <br /> rules and regulations of the San Joaquin County <br /> 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. 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on rover" side. <br /> Signed X _n - <br /> Title: )''�. v 1 Date: <br /> FO ART USE ONLY <br /> Cl <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date fin I Inspection by <br /> 1\ 1 Data <br /> Additional Comments: 6Jr/' �Z -S �+p�n 1e 1 AOL/ <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmen'wl Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 v <br /> FEE AMOUNT DUE AMOUNT REMITTEDT—F <br /> flu CA) /CASN RECEIVEpay FDATI PERMIT N0. <br /> . EN t1-111aEV.r/•ei g'C'l.(/� (�7 YB �r �f-Zysr <br /> EM '/-]e <br />