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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> l PERMIT EXPIRES 1 YEAR FROM -DATE ISSUED <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 /> r <br /> Job Address <br /> 3713 E Hammer Zane Stockton Lot Size/Acreage <br /> ,Owner's NameAddress p — Phone Watanabe Bros 8011 N Alpine Road 1 - <br /> "Contractor Clark Well, lnC Address 2024 E Charter Way License No. 371560 Phone 462-7676 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ m...DESTRUCTION [K Out of Service Weil X1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD, PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE A TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D171 Industrial %j.\ ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C:l <br /> Domestic/Private ❑ Gravel Pack.) > 0 Tracy �. Type of Casing Specifications <br /> — <br /> I'] Public 1:1 Other ``r Fl Delta 'Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth q I I Eastern Surface Seal Installed by <br /> Repair Work Done LJ•;. Type of Pumpf ` �:' H.P. 4� r Sr Work Done_ <br /> Well Destruction-_ ❑A Well Diameter 6 Sealing Material b Depth Bret R rc,Ir <br /> Depth 2�0 ( .:Filler Material & Depth �„� D �l�u <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> f available within 200 feet.) <br /> Installation will.serve: Residence Commercial__ Other 3 <br /> Number of living-units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑,'Type/Mfg f Capacity No. Compartments <br /> E PKG. TREATMENT PLT. ❑ ' Method of Disposal <br /> Distance to nesrest: Well :r Foundation Property Line b <br /> 't` r <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED C) Distance to nearest: Weil Foundation Property Line <br /> t <br /> SEEPAGE PITS ]'I Depth Sire _ Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line 4 <br /> DISPOSAL PONOS ❑ <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'certifiss the followiing: "I certify that in th`e-performance of the work for which this permit is issued, I shall not <br /> employ any son in such manner as to become',subject'to workman's compensation lavirslof California." Contractor's hiring or subcontracting signature <br /> certifies the II wing: "I ify that in the perform ce_ of i_he work fob which this permit is_issued, ahalLemploy_persons-subject-ta-workman:s•compensa-�•-- <br /> " nan'laws of a forma." ' <br /> The applica ust call f I qui ed tion omplate drawing on reverse side. <br /> ,signed Title: Sec-Tres Date: 6 July 90 <br /> k �I A2` R DEPARTMENT USE ONLY <br /> Application Accepted by __L�� C�A;�-'`i— Date Area <br /> i Pit or Grout Inspection by Date Final Inspection by Date <br /> i <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> ' Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEECK <br /> INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED by DATE PERMIT NO, � <br /> a EH1t�•2s 7.2 IREV. /K51 <br /> EH © 10 jQ0-17C-4 <br />