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APPLICATION 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 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. ' ,,,r k record Job Address 8457 S . Wolfe Rd City French C a'Ut Size/Acreage l a c r�e'L o f of Owner's Name Frank Resuel10 Address 8440 S Wolfe Rd Phone 982-0241 Contractor Clark Well , Inc Add,e,s2024 E . Charter Way LicenseNo.371560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELLX:5K WELL REPLACEMENT 171 DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 51 ' SEWER LINES DISPOSAL FLD. PROP LINE 10 r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 2 Dia. of Well Casing rr X X.KOomestic/Private X X®Xiravel Pack ❑ Tracy Type of Casing- P VC Specifications 11 Public Cl Other n Delta Depth of Grout Seal log, Type of Grout t i I irrigation —.Approx. Depth 11 Eastern Surface Sedl Installed by Clark Repair Work Done 0 Type of Pump Sub H.P. 1 1/2 State Work Done _ install Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION I I DESTRUCTION I I iNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of,living units: Number of bedrooms _ Character of aoil to a depth of 3 feet: Water table depth i SEPTIC;TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Lina V LEACHING LINE ❑ No. & Length of lines Total length/size �� ) FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS LI Distance to nearest: Weil 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 t7 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 t 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 at o a r t' ns Complete drawing on reverse side. Signed Title: V P Clark =dell . I n r pate: 8 June 92 TAAENT USE ONLY Application Accepted by r Date -22- Area Pit or Grout Inspection by //,' Date ��Final Erns'pection by Date Additional Comments: lj' V SS lo`z' 1 S Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.. f EKu-74tnl:v-rrMSr oW � L'�� Z $Zt� EN t1•Ia ✓r (3 S L9 f� V 7