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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 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. Job Address 4851 E. Woodbridge CitAcampo. Got Size/Acreage 2 Owner's Name Bon & Ardith 2t1e Address same Phone 369-1819 i Contractor Clark Well Address2024 E. Charter License No,371560 Phone-A62-767 6 TYPE OF WELL/PUMP: NEW WELL)f WELL REPLACEMENT C_ DESTRUCTIOrkk Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST;:SEPTIC.TANK, - .SEWER LINES-_ _D.fSPOSAL FLD. .PROP. LENS. FOUNDATION - AGRICULTURE WELL -OTHER WELL PITS/SUMPS . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. _ 4 � r , M Industrial r ❑ Open Bottom 0-Manteca Dia.-of'Well Excavation pia. of Well Casing " r f xC Domestic/Ptrivate `0 Gravel Peck • ❑ Tracy) fTypeWCasing St.EEl y„ ?_y t ` ` Specifications.1:JO g I') Public i i f_1 Other .n F1 Delta 'r Depth ofiGrout-Seal Type tautg 3 a ' Tof G . * - 5 a@zc I I frri{fation Approx..Depth _ •1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter l i ''LL Sealing'Material de'Depth.F-n:'+7 +, r+• Depth Filler Material b Depth TYPE OF SEPTIC,WORK: ,NEW_INSTALLAT.ION I,l REPAIR/ADDITION 1.1 DESTRUCTION I 1 INop yse tic system permitted it public sewer is available within 2 feet.) _ . Installation will serve: Residence _ Commercial Other Y ! 4 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT!❑ I Mathod of Disposal ' Distance to nearest: Well Foundation j Property Line y LEACHING LINE _ - 0 „ No. & Length of lines Total length/size FILTER BED F� [1 :Distance to nearest: Well - Foundation Property Line t SEEPAGE PITS 1 I 1 L Depth"' Size F Numti_er' SUMPS 'Ll Distance to nearest: Well Foundation ;Property Line DISPOSAL PONDS ❑ ' 1:M (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 Fm`��' _ - '—"� .. M Home owner or licensed agent's signature certifies the foflowing: 111 canify 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 that in the performanceof the work for which this permit is issued;I shall employ persons subject to workman's compensa- tion laws of California."f .: r - I The applicant must call r re i ed inspections. Complete,drawing on reverse.side. Signed X Mile vP Clark"Well keData 30- Oct 90 u FOR DEPARTMENTm USE ONLY Application Accepted by 1_ v' ,4'�� l Date `� 4Area / a e• Pit or Grout Inspectionmb y Date -.- - .�_ _ _ .. _ _.,. _ _ Fnal Inspection by Date Additional Comments: r�J Applicant — Return all copies to: San Joaquin County Public Health L ----- --� -- Services,.-Envi-rotnnental-Health•Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT pt1E AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO M---[—CASH �` qq EH 13-24 1REV.1/A5) �% A fH 54-2e O L 0-0