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2� • APPLICATION FOR PERMI* �,/ 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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 614 N Anteros City St-nr-kf-nn Lot Size/Acreage Owner's Name Beck & Ratto Address 7811 Kelley Drive Phone 473-7000- Contractor 7 —Contractor Clark Well, Inc Address 2024 E. Charter Way License No.371 56 none — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO ® t of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f') Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction 19 Well Diameter 81' Sealing Material & Depth 11 9 ' 6 6a-8k: hQt:t_ m to top Depth 1 1 2 ' Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I I INo 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 Distance to nearest: Well Foundation Property Line — LEACHING LINE 0 No. & Length of lines Total length/size iV FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number C) SUMPS LI Distance to nearest: Well Foundation Property Line 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 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 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 California." The applicant T/uus call or re di ' ction��II Complete drawing on reverse side. Signed X_/ �"( �� `Wi(J� Title: VP Clark Well, Inc. Date: 24 Oct 90 PR DEPARTMENT USE ONLY qq Application Accepted by Date �0 _ `� Area Pit or Grout Inspection by Date !� Final Inspection by �' � � '1� Date Additional Comments: Applicant — Return all copies to: San Joaquin County Public Health s^ Services, Environmental Health Permit/Services ` 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INF AMOUNT DUE OUNT REMITTED CASH RECEIVED BY DATE PERMIT*/NCO. + EH 13-211REV.rir.si �0.Q�c C() � :�d ��-�r} EN:t•Ta