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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209) 469-3420 46 8 - 3 y-d. p P 0 BOX 388, STOCKTON, CA 95201-0388 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( Complete in Triplicate ) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 749 E . Charter Way city St o ck t on Lot Si ze/Acreage 1 / 4 Acre Owner Name Darpetro , Inc . Address 749 E . Charter Way Phone 537 - 0771 Contractor Spectrum ExploratAdg,ti552825 E . Myrtlest Stoq_Ik9rQLnNp, 512268 Phone 465 - 8712 TYPE OF WELL/ PUMP. NEW WELL ONWELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 55 ' DISPOSAL FLD. PROP. LINE 1 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/ SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C1rr Cl Domestic/ Private ❑ Gravel Pack Trac Dia. of Well Casing 2 v T ype of Casing P V C 4 0 S c h Specifications 11 Public ❑ Other n Delta Depth of Grout Seal 10 , Type of Grout Cement I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Spectrum Repair Work Done ❑ Type of Pump H . P . State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth C e m e n t 10 Depth _ Filler Material i Depth TYPE OF SEPTIC WORK : NEW INSTALLATION i I REPAIR / ADDITION I I DESTRUCTION I I ( No septic system permitted if public sewer is available within 200 feet. ) Installation will sena: 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. Compartment PKG . TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ', LEACHING LINE ❑ No. d Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS O 1 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, 1 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 ust call I rall squired inspections. Complete drawing on reverse side. SignedX - L/-c Title: PresidentDate: 9 / 8 / 95 OR DEPARTMENT USE ONLYDate / / Application Accepted by / ` , I e Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to : San Joaquin County Public Health Services Environmental Health PermiVServices 445 N. San Joaquin, P.O. Box 388, Stockton, CA 95201-0388 FEE CK Z4 INFO /�,�� AMO�((UN))T DUE EA11111UNTREMITTED 1 R/ REIC�E.I\VED1 BV Fo PERMIIINO.EM lz.al lREV. I / relVVI ' 1 V I / a 's 4� V l `-� / l ' I� VO� Y/ Lg a