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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p 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 8724 Alhambra City Stlrn Lot SizeP/Acerea7ge 1S:2 yb Owner's Name Robert Shed Address 8724 Alhambra Phone 931 -2873 Contractor Clark Well Address 2024 E. Charter License N0.371 560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT30t DESTRUCTiOPkk Out of Service Well ❑ PUMP INSTALLATION XXX SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK 50 ' SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL 70 ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 Dia. of Well Casing 6 91811 I� IX Domestic/Private k Gravel Pack ❑ Tracy Type of Casing PVC Specifications 1 20 I'I Public 1-1 Other Cl Delta Depth of Grout Seal 100 Type of Grout A -,ar-k U I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Clark Repair Work Done U Type of Pump $t;b H,P. 3 State Work DoneTreT7__We_1l Well Destruction X3tk Well Diameter $" Sealing Material & Depth 13 _' 6, saek—betm to ,top Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 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. ❑ Method of Disposal r^� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size y FILTER BED ❑ Distance to nearest: Well Foundation Property Line y SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well 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 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: "1 certif in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californ' ." The applican s call f I re r in c' ns. omplete drawing on reverse side. Signed X Title: VP Clark Well Date: 23 Aug 90 F DEPARTMENT USE ONLY Application Accepted by Date Area l Pit or Grout Inspection by �'✓ Date b+ orb Final Inspectio by Date `� v Additional Comments: ' Applicant — Return all copies to: San Joaquin County Public Health �� ` SQ ervices, Environmental Health Pe t/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH CK i RECEIVED BY DATE PERMIT'NO. + EH 13.24(REV.l i n s) EH o4_26 1