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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 O BOX 2009, STOCKTON, CA 95201 PMMIT 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 1074 E . Bianchi Rd City— S t k n„ Lot Size/Acreage owner's Name West Lane R a C u e t C 1 Ukydress same Phone 4722100 i Contractor Clark Well Address 2024 E . Charter Way License rvo.371560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELV KIX WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK s e e bac 1tEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1-5-0 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing$ t' t] Domestic/Private X0 Gravel Pack ❑ Tracy Type of Casing Steel Specifications q I n xY' Public (;l 01he f1 Delta Depth of Grout Seal 100 r Type of Grout tL.;U I .1074 r, . Ti.anch ' kk�{ 1 n k I I I(rioation _Approx. Dept4 -f rEastern Surface Seal InstallaI4 Repair Work Da e,S7 LTp,ecpf mp �—u 1 h H.P. State Work Done_ /1 7 2 2 11 9II p 5 V Well Destruction ❑ Welt Diameter Sealing 1 6 �-al & Depth C l a r k W eO (Oth 2 0 2 Wlier MVtFr�i�iL&enept�h 5 ! .56b 46?- 7676 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is X x x available within 200 feet.) Installation will serve: Residence T Commercial_ Other Number of living units: Number Wib�dret'M C k Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK .O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 14" Method of Disposal c " ' X x Distance to nearest: Well Foundation qtr ea F Rroperty Line 10 1001 ek LEACHING LINE 1 0 7 4Cl-` No.�1Cd6ihho(-lines S tfotal Iengtylirta u FILTER BED , CI Distance to nearest: Well Foundation Property Line r -4722100 4e C Carle kac. quet L Ib ��ne r SEEPAGE PITS, LI'} Depth Sire• Number � . at'k 4v t_ 14 �u'._ L �„u j. tt'r wuv 7 ! t Jt7t1 fi62'-7Fi76 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 XIX X. 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 Co`un'ty b a t k. 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." 1 I+, 8 ]/8+r The appfica t c 1 0.11 q r Inspec ions. Complete drawing on reverse side. t u e 0 'Signed Title: VP-Clark W e ljll;,r) 'i n c Data: 18 D_e_c2._1 _____ ' F99 DEPARTMENT USE ONLY e r s Application Accepted by Date / Ar a / -57 _ Wct JLd 01, Pit or Grout'Inspection by Dao -L Final1 spection by Date Additional Comments: �� ` Applicant — Return all copies to: San Joaquin County Public Health o 22 cr - Services', vironmental Health Permit/Servit7ge 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK 11 RECEIVED BY DATE PERM17'NO, INF/�Or CASH / p . EM 13-24(REV.t/"5) l� f. 9 '�_ ! —�(""f EH 14-2e ! N X vT- di k Wei,,1 T n 16 Dec. 91