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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 O PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install therk rein described. This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the R d Regulations of San Joaquin County Public Health Services. Job Address 1 555 March Lane City Stockton Lot Size/Acreage 1 3 . 26 acres Owner's Name Moss & Craig Address 1919 Grand Canal ' Stockton Phone ( 209 477-550 P.o. Box 157 C57-522125 707 Cont,,ctor Bay Area Explorat,Pr9ss Suisun, CA 94585 License No. C57-5221 415one 64-21 31 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER XX Monitoring Well C� N/A Soil Boring XX DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES (3T DISPOSAL FLD. PROP. LINE 177�5 r FOUNDATION 50 AGRICULTURE WELL _!_A OTHER WELL N A PITS/SUMPS ray INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N/A U Domestic/Private ❑ Gravel Pack EJ Tracy Type of Casing None Specifications M Public C1 Other ❑ Delta Depth of Grout Seal TD to SurfaC%, of GroutNeat Porti rid Cl Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Bay Area Exploration Repair Work Done U Type of Pump N/A H.P. N/A tate Work Done— Well Destruction ❑ Well Diameter 4 if Sealing Material & Depth Grout to 'I'll Depth Approx . 60 r Filler Material & Depth None TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION 7l DESTRUCTION Cl (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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size 25 FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I I 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'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 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 Califrnls." The applicant m 's call for all y�quir ins, ions. Complete drawing on reverse side. Signed Title: President DBte: October 10 , 1990 tephen R . 77aF MENT USEONLY for Bay Area E ratio / (, 3 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 DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �) �PE//RMITT NO. . EH 13.24 IREV.Tinel ) 15 ;r6 (/ l/ �`!7.1 EH A-21111