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APPLICATION FOR PERIdIT ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOC'KTON, CA 95201 PERMIT EXPIRES 1 YEAR FRQM DATA ED (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 711 3 E. Cherokee Rd City Stkn Lot Size/Acreage 22 acres Nick 'Nicora Address same Phone 931 -3084 Owner's Name - Contractor Clark eller—Inc Address 2024 E Char er Wa License No.371 Phone 7Q76 TYPE OF WELL/PUMP: NEW WELL kX WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION RIX SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK ._.75 % SEWER LINES DISPOSAL FLD. PROP. LINE3 31 FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 10 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1' Dia. of Well Casing n ❑ Domestic/Private >0Z Gravel Pack ❑ Tracy Type of Casing Specifications l'1 Public C] Other n Delta Depth of Grout Seal Type of Grout X'Ofrigation _ Approx. Depth I I Eastern Surface Seal Installed byGlar- r Repair Work Done 0 Type of Pump cam— H.P. I F; _ State Work Dane F;*;;a l l Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION f I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence.Y..^. Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Tota) length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line Q SEEPAGE PITS l I Depth Size _ Number SUMPS El 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 became subli ct to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certif Ott Orman e f the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of Cali rni .' The applica I r 1 ti n . Co plata drawing on reverse side. Signed X Title: VP Clark Well Date: 23 July 90 ARTMENT USE ONLY Application Accepted by Dated a�yiy� �,,� Area Pit or Grout Inspection by f Date Final Inspection by�' ��/ �` -- — Date lr Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI-r'NO. INFO EN 13-24 IREV.I/A 5) 1 Q © EH;�•2e / W /�