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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 RERM11 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4618 Cherokee bane City Stockton Lot Size/Acreage 2 acres Owner Is Name$en Marracini Address same Phone 465-4-516 Contractor Clark Well, Inc__ Address 2024 E_ Chart--(--r WayLicense No. '�7'1 5—(l Phone4 fi 2-7676 TYPE OF WELL/PUMP: NEW WELXXX WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATI0N>gc SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 9 o t SEWER LINES DISPOSAL FLO. PROP. LINE3-C— FOUNDATION AGRICULTURE WELL OTHER WELL 112 ____ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 Dia. of Well Casing 6 51811 x[5Yaomestic/Private AX-1 ravel Pack ❑ Tracy Type of Casing StOG11 Specifications #4 0 I'I Public P Other n Delta Depth of Grout Seal 10 0 Type of Grout L gar_k + I Irrigation Approx. Depth I I Eastern Surface Seal Installed by C-1 ark _ s Repair Work Done ❑ Type of Pump Sub H.P. 2 State Work Done—it��t-aII Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth 11<11 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) i 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 LEACHING LINE ❑ No. & Length of lines Total length/size_ FILTER BED ❑ Distance to nearest: Well Foundation 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 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 California." The applicant p I for r i i cti ns. Complete drawing on reverse side. Signed X Title: VP Clark Well, Date:Inc 14 Nov 90 EQft DEPARTMENT USE ONLY Application Accepted by 2, Date (Air.) Area Pit or Grout Inspection by Date �Z �� Final Inspection by ` Date z� Additional Comments: Applicant - Return all copies to: 8an'Joaquin County Public Health jJ 6 Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 J7'ltty 1l.Y/ INFO FEE AMOUNT DUE AMMOOU�NT REMITTED CASH RECEIVED BY / DATE �PjERRMIT'NO./ a EH 13-21(REV.1/x51 EH 11.25