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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to S. Joaquin County for a permit to construct and/or install the work herein described This application is made in compli&nce with San Joaquin County Ordinance No 549 and 1662 and the Rules and Regulations of San Joaquin cth ny 'poccc VUnt eyY16y Market, Stanlslaus Job Address Washington, and American Streets __ C,ty Sto rkton Lot Site/Acreage Owners Name C_1ty of StoCkjon Address 425 North EI Dorad9__Stl-eet ______ Phone 209 X37-8538 Spectrum Exploration, Inc. 2365 Wigwam Drive (209) 465-8752 Contractor Address StocktolJCA 95205 License No 512268 Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT F) DESTRUCTION ❑ Out of Service Hell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L 14onitoring w IZ [3(soil borings DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom 0 Manteca Dia of Well Excavation 7 _trtr-hPc__ Ora of Well Casing J`l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing nnnP Specifications I 1 Public X(1 Other borings R Delta Depth of Grout Seal rnax_ 50 fee Type of Grout cement 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 0 Well Diameter Sealing H4aterial IF Depth cement Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted it public sewer is available within 200 feet I Installation will serve Residence_ Commercial— Other Number of living units Number of bedrooms Character of sort to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE ❑ No a Length of Innes Total length/size FILTER BED ❑ Distance to nearest Well Founaation Property Line SEEPAGE PITS 11 Depth Size — Number SUMPS LI Distance to nearest Well Foundation Property Line ' DISPOSAL PONDS ❑ I 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 Sart Joaquin County Home owner or Beensed agent's signature certifies the following ' I caitify 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 taws of California Contractor s hiring or sub-contracting signature certifies the following I certify that in the performance of the work for which this perrr4t is issued I shall employ persons subject to workman s compensa tion Laws of California - The eppiicant must call for all required inspections Complete drawing nr on reverse side r Signed Title Gac to s Date FOR DEPARTMENT USE ONLY 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 CASH RECEIVED BY DATE PERMIT NO Page I3C