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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> DY'iRlfT�l` EXPIRES 1 YEAR rRQH DATE__ISSUEA <br /> (Complete in Triplicate) <br /> Application is hereby mode to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> appl3" etion is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> J.oaqui County Public Health Services. <br /> 's` 111 N. Zuckerman Lane McDonald I6� Got Sine/Acreage <br /> nd +100 aces <br /> Job Address <br /> ownaraNameGardemeyer Const Add(ess1825 16th St Sac phone 916 447- 066 <br /> Contractor Clark Well Address 2024 E. CHarterWay License No. 371 560 Phone 462-7676 <br /> TYPE OF WELLIPUMP: NEW WELal WELL REPLACEMENT ❑ DESTRUCTION C] Out of Service Well Cl l <br /> PUMP INSTALLATION 29 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK 12 0 r SEWER LINES DISPOSAL FLM. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC_A_T2NS rr <br /> }f�l�Industrial O Open Bottom ❑ Manteca Dia, of Well Excavation G• Dia, of Well Casing 6 5 8 <br /> 1komestic/Private "f Gravel Pack ❑ Tracy Type of Casing PVC Specifications CL 200 <br /> M Public Ci Other 'IUCDelta Depth of Grout Seal ap rox 30 ' Type of GrouDentonite <br /> 0 Irrigation Approx. Depth a Eastern Surf& a Seal installed bVQ I arky <br /> Sub 1 1 %2 install <br /> Repair Work Done v Type of Pump H.P. <br /> Sate Work Done <br /> Welt Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i) REPAIR/ADDITION M DESTRUCTION G lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other *— <br /> Number of living units. Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El Method of Disposal <br /> Distance to nearest: Welt Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> r SUMPS Ul Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 end regulations of the San Joaquin County f <br /> Home owner or licensed agent's signature certifies the following: "I cariify that in the performance of the work for which this permit is issued, I shall not <br /> 4ploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> cirlifies 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 <br /> r tion'-laws of California." <br /> Tapplicent 1 fa 11 r q �� olnyypl dra ing on reverse aide. <br /> Signed Hue: VP Clark Well pate:28 March 91 <br /> FOR PARTMENT USE ONLY / r <br /> Application Accepted by Date Area <br /> r� fJ <br /> Pit or Grout Inspection by Date 3 Final Inspection y Date <br /> 4 t <br /> Additional Comments:1. A <br />� Applicant - Ratura�l.1 copiea to: pN JOAQUIN COUNTY PU9LIG HEALTH SERVICES .L!-¢.����� <br /> eC rOlJl �� Yrz y ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> { 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 85201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI7"N0. <br /> INFO f CASH /p <br /> . EH t]•l#rREV.I/It p� Si �o ( +7r '' - J r`- o" q Lvl <br /> 'P / 0 G V_PIN <br />