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APPLICATION SAN JOAQUIN COUNTY PUBLIC HE ES ENVIRONMENTAL HEALTH D V 1 445 N SAN JOAQUIN, PHONE ( 9 34 ...., P O BOX 2009, STOCKTON, C�I� l PERMIT EXPIRES 1 YEAR FROM SUED (Complete in Tripli a / Application is hereby made to San Joaquin County for a permit to construc at� y stall the ork Herein described. his application is made in compliance with San Joaquin County Ordinance No. 5 an tions of an Joaquin County Public Health Services. PW4-113 Job Address 1677; u i a n u City —Lath rop Lot Size/Acreage Owner's Name T r P a T P k—C R A a c A So n t gAddress 2 7()1 E- N p m M o r Phone 4 7 2— Contractor Clark Well . Inc Address 2024 R _ _CharfPr Warr LicenseNo371SF(1 Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENIXMX DESTRUCTION t of Service Well ❑ PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER U Monitoring Well _ri DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE C` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 2'! Dia. of Well Casing LI Domestic/Private XKXGravel Pack ❑ Tracy Type of Casing_ Steel Specifications NR J ;2 I'I Public [-I Other 1-1 Delta Depth of Grout Seal 1 (11 Type of Grout n n a Q- I I Irrigation ` Approx. Depth I I Eastern Surface Seal Installed by G 18 r E Repair Work Done U Type of Pump _ H.P. ___ State Work Done _ Well Destruction ❑ Well Diameter _ Sealing Material i Depth Depth Filler Material Z Depth sazraa �— — TYPE OF SEPTIC WORK: NEW INSTALLATION ' 1 REPAIR/ADDITION I I DESTRUCTION I I (No 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 O 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 FILTER BED 1-1 Distance to nearest: Well Founoatlon Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 cenif ft performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant all r I q re i i . Complete drawing on reverse side. Signed X Title: V P C1 ark_ W e 1 1 Date: 16 FL e b Oma/, _. FOR DEPARTMENT USE ONLY Application Accepted by _ Date _/ rea Pit oGrout Ipection by _ Date Final Inspection by Datn / Additional Comments: Y3 Applicant - Return all copies Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO FEEAMOUNT DUE AMOUNTREMITTED �K H RECEIVED BY D/AQTEt J PERMIT N0. EH 13.24 IR EV.rixsi/"/� EH 14-20