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APPLICATION SAN j*gKQUIN COUNTY PUBLIC HEALTH 'M-9RVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION RECEIVED 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 JUN 1..2_'1g9-'- SAN JOn,,QUIN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HEALTH SERVICES (Complete in Triplicate) ENVIRONMENTAL HEAaH 01VISION 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 5858 Morgan Place City Stockton Lot Size/Acreage 5.69 acres Ownee�f�ame s. Roberta Kaitz Address 20880 Baker Rd, Suite 9 Phone (510))/ 582-1997 ll.Hygienetics Env. Svs Address 677 Oakport St. Stel St. No. Phone 5 10)71 s -28 s onsu� TYPE OF WELL/PUMP: NEW WELL ❑ ELt`R rP_EXC tMENT Cl DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C$ Monitoring Well U il borings DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROPLINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications 1"1 Public FI Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. __ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 O Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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, I shall not employ any person in such rnanner 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 must call for vilequ' ed inspections. Complete drawing on reverse side. Signed l� ( ( Title: Director Hydrogeol./Env. Eng'Date: June 11, 1996 FOR DEPARTMENT USE ONLY Application Accepted by Data C? ' a ^� Area _ 68 Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 790 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. n�oe 13A EH 13-24 tFIEv.„A„ EH 14-7e �ff Ec