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APPLICATION FOR PERIII�j t� I `� ; t SAF JJyOAQUIN COUNTY PUBLIC HEALTH SfiRVICfiS ENVIRONMENTAL HEALTH DIVISION PIIts 12 1992 P O BOX 2009, STOC%TON, CA 95201 01ti yINC01JNIY O J (209) 468-3447 Ill PERMIT EXPIRES 1 YEAR PROM DATE ISSUSUr" io1#1" OIf3�G11i��1 �'ry B-3 (Complete in Triplicate) [ Application Is hereby aude.to San Joaquin County for a permit to construct and/or Install the work herein described. Thisapplicaf Joaquin Coo ie Pude in colthSSery with s. Ban Joaquin County Ordinance No. 549 and 1862 and the Ru and f PAP Joaquin County Public Health Services. 1 24 So. Hunter Street Stockton Job Address City Lot Sis cr C S Owner's Name San Joaquin Co. "Address 222 E. "Weber St . , Room 675 phone 209-468-3252 Spectrum contractor Exploration Address 2825 Myrtle St . License No. Phone 209-465-8- TYPE 09-465-8 TYPE OF WELL/PUMP: NEW WELL ❑ "" WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EI$Or JoBttoring Well LT F DISTANCE TO NEAREST: SEPTIC TANK 0 'SEWER LINES apps. 551 DISPOSAL FLO.+150'PROP. LINE annr. 101 FOUNDATION 3-6 1 AGRICULTURE WELL +150 t OTHER WELL +150 1 PITSISUMPS +1501 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q Public I:1 Other ❑ Delta Depth of Grout Seal �I �_ -Type of Grout Neat Cemen U lrriation _A Bentonite Slurr V Approx. Depth ❑ Eastern Sudan Soul Installed by V Repair Work Done ❑ Type of Pump H.P. State Work Dona_ Well Destruction ❑ Well Diameter Sealing Material A Depth Neat Cement /Bentonite Slurry \ Soil Sampling Depth Filler Material L Depth Same TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION G DESTRUCTION G INo septic system permitted it public sewer ar available within 200 feet.) ^ Installation will serve: Residence_ Commercial_ Other - f, Number of living units: _ Number of bedrooms Character of $00 to a depth of 7 feet•. Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 'r PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. g Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lim SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby comity that 1 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 subcontracting signature certifies the following: "1 LMify that in the rlormanes of the work for which this permit is issued, I shell employ persons subject to workman's eompenw tion laws of I or la." The applicant z2at for 1 e aired in ,�jons. plate drawing onlsverse tide. (, q Signed X C) Title: �Cfti.A. C�•IC/"':a Data: (�� FOR DEPARTMENT USE ONLY �"� Application Accepted by 6L I _ Date Z- Area: 23 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 443 N SAN JOAQUIN, P O BOE 2.009, STOCKTON. CA 95201FEE k INFO AMOUNT DUEAMOUNT nEMITTED 'JrK RECEIVED BY D TE PERMIT NO. yn� nf� . EN UN IAN.vxei SV YaOV � � ? � EN:a.b 1