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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 1 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 vith San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services Job Address 530 East Market Street CifN Stockton Lot bize/Acreage 1 Owner NameStocktQn_ Neyvspp:rs _ In Address 530 East Market Street Phone(209) 546-8249 Spectrum Exploraton, Inc. 2355 Wigwam DRive Contractor Address:Stockton _ -CA -95105 _ License No 57 22fi8 _ Phone465-87 TYPE OF WELLIPUMP NEW WELL ❑ WELL REPLACEMENT i1 DESTRUCTION ❑ Out or Service Well E1 PUMP INSTALLATION ❑ SYSTEM REPAIR �, OTHER E( Monitoring Well DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PRO S INE borings) FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i- Industrial ❑ Open Bottom D Manteca Dia of Well Excavation 2-1 Dia of Well Casing none r Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ nQne Specifications 1 + Public IX Other CXDeha Depth of Grout Sea[rI1aX 20 feet Type of Grout cement I I tfri0alion — Approx Depth 1 I Easrern Surface Seal Installed by Repair Work Done L7 Type of Pump H P — State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Cement Depth Piller Material ti Depth TYPE OF SEPTIC WORK NEW INSTALLATION , I REPAIRrADDITION I i DESTRUCTION 11 (No septic system permitted 41 public sewer is available within 200 feet 1 ' 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 ❑ Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Line I LEACHING LINE El No d Length of lines Total length/size FILTER BED Cl 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 or licensed agent a signature certifies the following I canify that in the perlormance of the work for which this permit is issued I shall not employ any person in such manner as to become subject to workmen s compensation laws of California Contractors hiring or sut>-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 apphtant/mu�m call for all required inspection: Complete drawing/o,,n reverse side Signed X 1[1/�-� 1- Itir Tnle L"�c�C�,i i i' C �``•,•`wA7/ �L r I Date FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments applicant - Return all copies to San Joaquin County Public Health Services Etivironmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEp CK 9 INFO CASH RECEIVED BY DATE PERMIT NO