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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 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE I§SUED <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 /> fff application is made in compliance'vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 4 <br /> Job Address 3713 E Hammer Lane City Stockton Lot Size/Acreage <br /> f <br /> Owner's Name Watanabe Bros Address 8014 N Alpine Rd Phone 931-3557 <br /> f Contractor Clark Well, Inc. Address' 2024 E Charter Way License No. 371560 Phone 1.162-7676 '. ;. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 5d Out of Service Well Cyt <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well CJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTAJRE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ <br /> n Industrial C] Open Bottom ❑ Manteca Dia.oflWell Excavation Dia. of Well Casing }� <br /> [� Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public C] Other fl Delta ""°"�" Depth of Grout Seal Type of Grout <br /> I lrntaauon _.Approx. Depth 11 Eastern Surface Seal installed by <br /> Flepau Work Done 0 Type of Pump t H.P. tate Wor Done <br /> well Destruction 6 Well Diameter 1.6i k Sealing Material & Depth <br /> f F'? Depth 34*, u,+ F'i11erMaterial & Depth . 17rJ♦ A­(C-- Q$A <br /> 5 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADD,ITION I I DESTRUCTION I I (No septic system permitted if public sewer 1s <br /> of E available within 200 feet.► w <br /> installation will serve: Residence,.,_,...Y Commercial_ Other I <br /> Number ofaiving units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: " - ' Water table depth <br /> SEPTIC TANK 0 Type/Mfg ` S'I +-� ¢�Cipacity- � No. Compartments <br /> PKG. TREATMENT PLT. C7 " k Method of Disposal <br /> III Distance to nearest: Well foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines M - * Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundastion Property Line <br /> f SEEPAGE PITS 11 Depth Size �T `Number <br /> l SUMPS CI Distance to nearest: Well ' Foundation_ Property Line <br /> �215POSAL PONDS , ❑ <br /> I-'FSaieby,certify that I have prepared this application and that the work will,be�doria in eccordan_c_e,with San Joaquin county ordinances,state.laws,_and <br /> iutes`and iegGlafi6ns af'th8 San Joaquin County <br /> r Home owns r licensed agent's signature certif.as he following: "I certify that in the performance of the work for which this permit is issued. I shall not <br /> employ any, san in such manner as to become bject to workman's compensation laws of California." Contractor's hirinolor sub-contracting signature <br /> certifies th fo owing: " c rtif that in parlor nce of the work for which this permit is issued, I shall employ persons subjeci to-workman's compensa= <br /> tion laws o lifornia.' <br /> The applic st I or eq r i Ctio Com ete drawing on reverse side. �`e <br /> Signed X tris: Sec-Tres Date: 6 July g0 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date 01, D Area 4 <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 /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> rFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 17-2/(REV.t/K 5) of- <br /> EH 1426 IIPP <br /> k <br /> .- R <br />