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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,. PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT- EXPIRES 1 YEAR FROM D TE 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 conTliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7 9 8 8 S E J M City F r o n� t Sixe/Acreage Dick Wamirez as Agent for ownXc1;;r ame Phone 952-6664 wrier s ame Contractor Clark Well Address License No.'s 7 1 5 h n __Phone — 5597 I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOf(5I Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C3OTHER ❑ .14onitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public I7 ther fl Delta Depth of Grout Seal Type of Grout 7988 5 �. r I SZE- ami] I I Ifripation Approx. Depth I I Eastern Surface Seal Installs by H p, State Work Done _ )i3epai��W3tk,�QRn4nLzl aTypeFo��Q -�:,. w�: � 4_6_ -tial i Depth Well Destruction e/Well Diameter tt Sealing!la Bentonite Depth biller gaterial i Depth Q 7 + TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INailableo septiw shin system perettted if public sower is it Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal t Distance to nearest: Well Foundation Property Line t 1 I "Total Ilan ftlilyizs - LEACHING LINE LI No.lr8 Length of lines 9 ' Foundation Property Line FILTER BED,m i_ t ,�, C] .Distance,to neer, - y Well, L I, c rt C. SEEPAGE PITS 1 1, Depth Sue Nufnber �.. rI I r k. 4tiI. 1 Lell U 1_=-F SUMPS LI Distance to nearest: WFoundation Property Lirn DISPOSAL PONDS ❑ 1 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 Sen 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 foNowing:'9 cenify 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 Cali arnia." ; I The applicen t all all egr(ir to io mpleta Arawing on reverse side. Signed [J Title: 31 pr j rk;T.r @ i I ;- — Data: —2 6—4r—T PARTMENT USE ONLY Application Accepted by Date a) ��` ' ` �• Pit or Grout Inspection by Date ` Final Inspection by Oat6 Additional Comments: I Applicant - Return all copies to: San Joaquin County Public-Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMWNO. INFO �j 5 �. EH 13-21 tREV,rinei w'� r Or� V�� / Vad-3 EH 14-M VP ( lark ltie1 .L 26 Apt 93