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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> p MIT 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 cotwliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 9460 E. Eight Mile Rd CityS } Lot Size/Acreage <br /> C1 �o-rlas <br /> Ms. SantoniAddress _ same Phone 333-1218- <br /> Owner's Name -, <br /> Contractor Clark Well" Address .--2024 E. Charter License N071 560 Phone 462-7676 <br /> TYPE OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R_X DESTRUCTION XXOut of Service Well ❑ <br /> PUMP INSTALLATION 13SYSTEM REPAIR C7 <br /> OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 75r SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL-0 OTHER WELL_la�__ PITS/SUMPS <br /> l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS }� <br /> U) Industrial ❑ Open Bottom C7 Manteca Dia. of Weil Excavation Dia. of Well Casing <br /> Type of Casing— -- <br /> xKl Domestic/Private Gravel Pack ❑ Tracy YP g w PVC - Specifications C 1 900 <br /> I'I Public CI Other F1 Delta Depth of Grout Seal 100 Type of Grout <br /> I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done 11 Type of Pump H,P, State Work'Done_ <br /> Well Destruction 13 Well Diameter <br /> w Sealing Material & Depth -' M tO tOp <br /> Depth ^Filler,Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I Mo septic system permitted it public sewer is <br /> available within 200 feet.) i <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments r <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 0 Distance to nearest: Well Foundation Property Line <br /> ) <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> 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 /> 4 certifies the following: "I at in a performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of Calif nia <br /> The applicant it 1! a re 'ired s tion Complete drawing on reverse side. <br /> Signed Title;VP Clark Well Date: <br /> I FOR DEPARTMENT USE ONLY <br /> . ^� <br /> 111 Application Accepted by Date 3 Area <br /> Pitarc6roxiinspection by Date nal Inspection by Date <br /> 11 d � <br /> I <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health ,nl� <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'N0. <br /> INFO CASH <br /> . <br /> EH 13-24(REV.1/m 51 <br /> EH 14,26 <br />