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- APPLICATION FOR PERMIT <br /> i $AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � t <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> C P O BOX 2009, STOCKTON, CA 95201 <br /> PERVIT R%PIRES 1- :YEAR FROM DATE UQUEO <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 4932 S # City Stkn Lot Size/Acreage <br /> Owner's Name He 1 Address Phone 931 -1121 <br /> Contractor Clark Well Address 2024 E. Char <br /> License No. -17-1-5L6-0—Phone - <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT [} DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE -2_-% <br /> FOUNDATION AGRICULTURE WELL OTHER WELL-r,-' PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ <br /> n <br /> { 1,2 ..� Dia. of Well Casing 62-- <br /> XR Domestic/Private <br /> XZ Gravel Pack ❑ Tracy Type of Casing _ Specifications.C-1: 4 2_ <br /> f"i Public El Other fl Delta Depth of Grout Seal 100 , Type of GroutgpptQr; t <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal installed by C-1 ark _ I! <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION f I REPAIR/ADDITION I } DESTRUCTION i I (No septic system permiZPtjblicer isavailable within 200 feet <br /> Installation will serve; Residence_ Commercial_ Other r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I 1 <br /> Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg j <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth I Size <br /> Number <br /> SUMPS LI Distance to nearest. Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> 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. <br /> rules and regulations of the San Joaquin county <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I tin he Perfo►manc of the work for which this permit is issued, I shall employ <br /> tion laws of Cali ni p p y persona subject to workman's compensa- <br /> tion <br /> applica m a r q red i ons. ete drawing on reverse side. <br /> Signed X <br /> � Title: VP Clark <br /> Date: 30_AugD�_,� <br /> R DEPARTMENT USE ONLY o <br /> Application Accepted by Date v~3�� Area <br /> Pit or Grout Inspection by 5 �__ Date 1 yU Final Inspection by SS aim_- Date 3J �,' I <br /> Additional Comments: ate yg <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., F 0 Box 2009,•Stockton, CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTEDCK <br /> INFO CASH RECEIVED E)Y DATE �PERMIT'NO. <br /> . EH 14-2k(REV,iia+5> Q-1 e0C� <br /> EH 74.26 llJl \ ' <br />