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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 FRQM_DATE ISSUED (Complete is 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 4511 Pacific Ave CityStockton Lot Size/Acreage Mr. Balwinder Brar Owner's Name Arco Mini Mart Address same Phone 4 7 3— Contractor Clark Well Address 2024 E. Charter Way License No. 371 560 phon462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION>CXOut 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 F-1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �Di II Casing D Domestic/Private Gl Gravel Pack Ll Tracy Type of Casing Specifications I'I Public I.1 Other 11 Delta Depth of Grout S al Type Grout I I Irrigation ,_._,. Approx. Depth I ('Eastern Surface Seal In tailed by Repair Work Done 0 Type of Pump �� H.P. State Work Done Well Destruction ❑ Well Diameter 4 Sealing Material & th 2-test bares Depth 16 ' & 23 Filler Materia]. & Dep TYPE OF SEPTIC WORK: NEW INSTALLATION[ I REPAIWADDITION i I DESTRUCT( No septic system permitted if public sewdris aval Installation will serve: Residence— Commercial— Other r 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 ❑ No. & Length of lines Total length/size n FILTER BED [--1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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 st fo 11 req ed ' trio C plate drawing on reverse side. Signed )( Title:VP Clark Well Date: 25 Feb 91 FOR DEPARTMENT USE ONLY Application Accepted by 0 LrA.�yyData ArAn Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EH 12 (REV.I/n51 EH 41.4.2a i