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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES_ 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made,in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> F 4 Job Address 9550 N. Hwy 88 _.......___ CityStkn Lot Size/Aceageacres <br /> Owner's Name Eddie Feggiar0 Address Same Phone <br /> Contractor Clark Well Address2024 E. Charter Way License No371 560 Phone 462 7676 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTXV-Q DESTRUCTIOMIC Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL S+ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 2" Dia. of Well Casin& 8 rt <br /> X Domestic/Private k1XGravel Pack ❑ Tracy Type of Casing Specifications X1,2_ <br /> 'l Public El Other ❑ Delta Depth of Grout Seal 100 , Type of Grout-9- Sack <br /> I I Irrigation —.Approx. Depth t I Eastern Surface Seal Installed by r-1 rk__ <br /> kRepair Work Done U Type of Pump H.P. State Work Done <br /> I Well Destruction ❑ Well Diameter 6 5181 Sealing Material & Depth 9 sa r-k -90 <br /> Depth �� + _ Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is P <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soll to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size___ <br /> FILTER BED i=1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> 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 <br /> t rules and regulations of the San Joaquin County <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: " that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Celifo <br /> The applicant s c f r r ired in ctions. Complete drawing on reverse side. <br /> Signed Title: VP Clark Well, IncT Data: July 90 <br /> FOR DEPARTMENT USE ONLY /3 / <br /> Application Accepted by Date �I Area �! qS•s <br /> Pit or Grout Inspection by pate �� �� Final inspection by E� l Date <br /> Additional Comments: �qS <br /> f <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE K 11 <br /> INFO AMOUNT DUEAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> I + EH 13-24{REV.1/n 51 <br /> € EH 14-Is r r - ! 1 3/ 'r1 .'s 0 -09O <br /> 4 <br />