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APPLICATION FOR PERMIT <br />) <br /> S,'�N JOAQOIN COUNTY PUBLIC HEALTH STRVIQRS <br /> a ENVIRONMENTAL HEALTH DIVISION ' <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 ,. <br /> DL'1?U T EMIRES 1 YEAR FROM DATE <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 or San <br /> Joaquin County Public Health Services. <br /> S of 3713 E Hammer Lane city. <br /> SJtOCktOn Lot Size/Acreage <br /> Job Address ° <br /> Watanabe Bros Address 801.4 N Alpine Road Phonei'93 <br /> i Owner's Name • <br /> Contractor "" C lark Well, InC. Address <br /> 202+ E Charter Wa License No._..32 5b0 Phone 462-7676 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D_ DES TAUCTION FOut of Service Well ): <br /> OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> �DISTANCE TO NEAREST: SEPTIC TANK f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> `-, <br /> INTENDED USE !;TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing J <br /> Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> C] Domestic/Private 0 Gravel'Pack ❑ Tracy Type of Casing <br /> Depth of Grout Seal Type of Grout <br /> ❑ Oelta , q <br /> I') Public I.1 Other -. " tV <br /> l I Irrigation ____.Approi.NDepth I I Eastern Surface Seat installed by <br /> ;i Repair Work Done 0 Type of Pump H.P. State.Work Done <br /> 1,0 u Sealing Material 6 Depth 1" <br /> E`Well Destruction ❑ Well Diam�e1 Depth >t ` ; Filler Material 8 Depth t <br /> ! TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is y <br /> t available within 200 feet.) <br /> i Installation will serve: Residence— Commr3rciaE Other <br /> Number of living units: Number of bedrooms <br /> `1 Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK; ❑ Type/Mfg ' Capac iyi• No. Compartments <br /> ' PKG. TREATMENT PLT. ❑ s t i Method of Disposal <br /> ' <br /> well Foundbtian Property LineDistance to nearest: <br /> LEACHING LINE C1 No. & Length of lines Total length/si e- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth 'I �' II, Sue _ _ Number <br /> SUMPS 0 Distance to nearest: Well. Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby cert 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 r u tions of the San Joaquin County I <br /> Home own r o ficensed g nt's signature certifies the fol ing: "I certify that in the performance of the work for which this permit is issued, !shall riot <br /> or an 'per on in au h nner as to b me subjec to workman's compensation laws of California," Contractor's hiring or sub contracting signature�1 <br /> certifies the oll wing: " ca fy that i ormance f e work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of 'ornia." <br /> Theappli u t cal f al uir i ti s. Co ete drawing on reverse side. <br /> k Signed - Title: See—Tres Date: 6 July 90 <br /> F DEPARTMENT USE ONLY p " <br /> Application Accepted by f Date �~ `� Area <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> k 1601 E. Hazelton Ave., F O'Box 2009, Stockton, CA 95201 <br /> FEE OUNT Dt1E AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•N0. <br /> INFO <br /> « EH 13-24 1 REV.I/A 51 �t D� f tr/l (✓ 1,10✓ • . <br /> EH t4.2tt <br />