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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sam Joaquin County tar a permit to construct and/or install the vork herein described This application Is made In compliance with San Joaquin County Ordinance No 549 and 1$62 and the Rules and Regulations of San Joaquin County Nb ibjealt'OcK 3erviDouged by Market, Stanislaus t-ITJob Address Washinaton, and 6aiguran SIrpels c-tv Stockton - Lot bize/Acreage Owners Name Clty of Stockon Address 425 -North EI Dorado Street _ Phone 2 937--8538 Spectrum Exploration, inc. 2365 Wigwam Drive (209) 465-8712 -- Contractor r _Address-5.,toekton, CA9205__ License No 5i 2268 Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT E i DESTRUCTION Cl Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I- Monitoring Well 0 �soll borings) DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PRO LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i industrial ❑ Open Bottom 0 Manteca Dia of Well Excavation 2 inr'hPS Dia of Well Casing nnnp i 1 Domestic/ ❑ Gravel Pack ❑ Tracy Type of Casing_ none Specifications I` I Ptiblic R Other (borings)IR Delta Depth of Grout Seal r3aX_ 50 feet Type of Grout rPMCnt 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 Materiallit Depth Cement Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION i I REPAIR/ADDITION i 3 DESTRUCTION I I (No septic system permitted if ptiblic sdwer is available within 200 feet I Installation will serve Residence_ Commercial _ Other Number of living units Number of bedrooms ` Character of sod to At depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capactty No Compartments PKG TREATMENT PLT O Method of Disposal r Distance to neerest Well Foundation Property Lina LEACHING LINE ❑ No b Length of lines Total length/size FILTER HED ❑ Distance to nearest Well Founaation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 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 ar licensed agents signature certifies the following 'I comfy 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 subtest to workman s compensation laws of California Contractor's hiring or sub-contraettng 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 a cornpsnsa tion laws of California ' / The applicant rust call for all required inspections Complete drawing on reverse side -sYvr / ds+-►C� Signed '--- x Title &Q-t, S r f Date FOR DEPARTMENT USE ONLY I Application Accepted by Date 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 Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED =ASH RECEIVED BY DATE PERMIT Np N fie 13,