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+ i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH D`:.' 3ION 445 N SAN JOAQUIN, PHONE (:: 19)468-3420 P 0 BOX 2009, STOCKTOii, :A 95201 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 with Sea Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 2130 West Washington Street City Stockton Lot size/Acreage Owner's Name port Of Ston Address P.O. Box 2089, Stockton, CA Phone (209) 946-0246 Sierra-Pace i ' Groundwater 4911 Windplay Drive, #4 /Contractor Consultants, Inc. Address E1 Dorado Rills, CA License No. CEG 1133 Phone (916) 933-1 68 TYPE OF WELL/PUMP: NEW WELL C3 WELL REPLACEMENT Q DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER M Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES N/A DISPOSAL FLO. N A PROP. LINE 200 feet FOUNDATION � AGRICULTURE WELL -§-/-A— OTHER WELL N A PITS/SUMPS N�A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O , C1 Industrial C2 Open Bottom Q Man[eca Dia. of Well Excavation -� Dia. of Well Casing N/A n Domestic/Private ❑ Gravel-Pack ❑Tracy Type of Casing none Specifications (I Public M Other M Delta Depth of Grout Seal 111 Type of Grout Bentonite I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump N/A H.P. State Work Done Weil Destruction O Wu Diameter WIN Sealing Material & Depth Bentonite A Depth N/A Filler Material i Depth Bentonite TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/AOOITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms NOT APPLICABLE Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PCT.❑ Method of Disposal Distance to nearest Well Foundation Property Line LEACHING UNE D No. b Length of tines N/A Total length/size FILTER BED O Distance to nearest Wed Foundation Property Line SEEPAGE PITS I I Depth N/A Size Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I haw prepared this application and that Me 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:"1 certify that in the performance of the work for which this permit is issued. 1 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:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's Compensa- tion laws of California." The applicant ( r all required'inspections.Complete drawing on reverse side. Signed Title: senior Englneerincr Geologist Data: FOR DEPARTMENT USE ONLY Application Accepted by �2� Date �7__? Are Pit or Grout Inspection by Oat* t ,d Final Inspection by • Additional Comments- -- Return all copies to: San Joaquin County Public Health Services b Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stlta, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK J RECENEO BY OATE PERMIT,NO. INFO CASH �ff� E111124 IR V.1In 91 � �-_,5-f3 �3-�✓� EN 14.26