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APPLICVPTON SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IIIVIRommENTAL HEALTH DIVISION 445NS (209)468-3420 2 BOX 2009, STOCKTON, CA) 420 95201 P OLl Li R 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 San Joaquin County Ordinance No 549 and 1862 and the Rules amd Regulations of San Joaquin County Public Health Services. Job Address City Stockton Lot Size/Acreage 8,000 Sq ft Owners Name .Tack Fetzer Address P•0* Box 543, Clements, CA 95227Phone 209-368-3638 3663 Omec Circle ContractorB5F Drillingz Address RaUghoCordova, CA 957k2censeNo 519428 phone - 4 TYPE OF WELL/PUMP NEW WELL aX WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Nonitortrtc Voll DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS h INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl industrial ❑ Open Bottom ❑ Manteca Dta of Well Excavation i' pia of Well CastnV 'g r' n 1'I 0amestic1prrvem EX Gravel Pack ❑ Tracy Type of Casing PVC Specifications I 1 Pnhlic 1 I Other f"1 Delta Depth of Grout Seal 58 r { 11rrUation 9QApr pox Depth I ! Eastern Surface Seal Installed by Type of Grout_ Gement Repair Work Done 0 Type of Pump NomH P State Work Done • Well Destruction ❑ Well Diameter Z Sealing Material L Depth Cement to Bentonite Sea - 681 Depth_. go,- _ Tiller Material i Depth Silica sand filter pack - 70' TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION t 1 DESTRUCTION I I (No Septic system permitted if public serer ss available within 200 feet Installation wd Residence _ Commercial — Other Number of living units r of bedrooms Character of soil to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg opacity No Compartments PKG TREATMENT PtT p Method of Disposal Distance to nearest e 1 Foundatio Property Line LEACHING LINE ❑ No 8�Ihof fines Total long[ e FILTER BED ❑ tanarest Wali Foundation Property L n r SEEPAGE PIT I I Depth Size Number SUMPS L] Distance to nearest Well - ;A Foundation Property Lino— 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, stats laws, and rules and regulations of the San Joaquin County Home owner or licensed agent a signature certifies the following "1 certify that in the performance of the work for which this permit Is issued, I shall not ampiny any person in such[Wanner as to become subject to workman a compensation laws of California ' Contractor's hiring or sub.contracting signature certifies the following I certify that in'he performance of the work for which this permit is issued I shall employ persons subject to workman s compansa non laws of Califomia" The spplica t must call for all requir 'inspections Complete drawing o averse side Signed X TitleDate D ARTME T USE ONLY Application Accepted by Date ? %+ Ares J Pit or Grout Inspection by Date _ Final Inspection by Date Additional Comments Applicant - Return all copies to San Joaquin County public Health Services p Environmental Healt4 Permit/Services I 445 N San Joaquin, P'0 Box 2009, Stkn, CA 95201 FEE [NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERM17 NO g EH t)71'REV I 5J ��oa .p {) 5, 1 M�3 l�L/J�(J) fw I�M (Lfq w �