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APPLICATION SAN JOAQUIN COUNTY PUBLIC RVICES ENVIRONMENTAL HEALTH D ON -- wmmwaysowmwo I 445 N SAN JOAQUIN, PHONE 8-3420 y�jZ P O BOX 2009, STOCKTO , LUl PERMIT EXPIRES 1 YEAR FROW4 T.R.Rurn (Complete in Tripl c9) 7 ' Application is hereby made to San Joaquin County for s permit to constru t or" i This application is made in compliance with San Joaquin County Ordinance No. an 2 and the Rules and Regulations of San Joaquin County Public Health Services. Well No PW10-138 Job Address 16777 S . Howland Rd city Lathrop Lot Size/Acreage Owner's Name TreaTek—CRA as Agent Address2701 E . Hammer Phone 472-202 Contractor Clark Well Address 7D24F L h a r t e r License No.3 71 5 6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTx[ x DESTRUCTION -ut of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L] 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 n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation 1 2 Dia. of Well Casing " 71 Domestic/Private xU firavel Pack O Tracy Type of Casing__ S t e e l Specifications n 1 2 I'1 Public (1 Other I-1 Delta Depth of Grout Seal 12 Type of Grouter� 6 I I Irrigation __ Approx. Depth I I Eastern Surface Sedl Installed by C,l t. � Repair Work Done U Type of Pump _ H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth h Depth Filler Material & Depth Cis a E k 6 2 P d 4 semen t TYPE OF SEPTIC WORK. NEW INSTALLATION 11 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. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED C) Distance to nearest: Well Founcation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 cert' 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 applican call or II to -6d ctio s. Complete drawing on reverse side. Signed Title: VP Clark Well Date16 Feb 94 FOR DEPARTMENT USE ONLY/A/ / / Application Accepted by _ Dace —! 7 �� Area �( � 1 9 y Pitot�r�ou,)nspection by, Dates Fina l Inspection by z" Datamac' Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH/ RECEIVED BY DATE PERMIT NO. EH 13-211REv,rinsr v �O �/T3� EH 14.26 j /ICJI / (CCJII