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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �. ENVIRONMENTAL HEALTH DIVISION +. 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIJ r EXPIRES 1 YEAR FROM DATE '� (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. 949 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. JobAddress8724 Alhambra City- Stkn Lot SiXAc eagge2 Sib Owner's Name Robert Shed 8724 Alhambra Address Phone 931 -2873 Contractor Clark Well Address 2024 E. Charter License No.3 71 5 6 0 -Phone462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTS DESTRUCTIOPkK9 Out of Service Well ❑ PUMP iNSTALLATION)C?EX SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK _50 ' •„_ SEWER LINES DISPOSAL FLD, PROP. LINE _J 0' FOUNDATION AGRICULTURE WELL OTHER WELL2-0-L— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing 6 5 f fi'r N Domestic/Private k Gravel Pack 0 Tracy Type of Casing Specifications 1 20 � I'i Public is Other n Delta Depth of Grout Seal 100 T ype of Grout__�, �a r�k i I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump SUa-- H.P. State Work Done Fflove Well Destruction xtj< Well Diameter Sealing erMatial & De r 11 $ Depth 11– , Depth Filler Material & Depth 60 saek m to .top 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.) y7 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 0 Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line 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: "I cenif 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 f re r in c ' nmplate drawing on reverse side. Signed Title: VP Clark Well Date: 23 Aug 90 F DEPARTMENT USE ONLY Application Accepted by L ( Date –D�— – � Area } Pit or Grout Inspection by / L Date a ��' Final Inspectio by Date r1 Additional Comments: 01,X , Applicant – Return all copies to: San Joaquin County Public Health sP acT ervices, Environ-ental Health Pe t/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 �( 7 d FEE AMOUNT DUE AMOUNT REMITtED CK INFO CASH RECEIVED BY DATE PERMIT NO. + EH 13-24[REV,t i n sl ] (/ 44, 1 (J '(�} 2�� W