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!y APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION k 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DATE- ISPUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aid:Regulations of San Joaquin County Public Health Services. 371.3 E Hammer Lane City Stockton Lot Size/Acreage Job Address M Watanabe Bros Address 8014 N Alpine Road Phone. 931-35557 Owner's Name Contractor Clark Well, Inc. Address 2024 E Charter Way License No, 371560 Phone 462--7676 .TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT.❑ DESTRUCTION ® Out of Service Well Ml Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � ,A* -DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL r'- OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREArl CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca � "Dia. of Well Excavation r a Dia. of Well Casing ' Specifications _ � C:3 Domestic/Private ❑ Gravel Pack L1 Tracy ¢ Type of Casirg �` f - I'1 Public Cl Other (� pelta ± Depth of Grouts5 eal « Type of Grout I I irrigation __.Approx, Depth l I Eastern Surface Seal Installed by Repair Work Done 11 Type of Pump H.IP. r S ate Work one r P baling Material & Depth Well Destruction 6 Well DiameterS r 4 Q Depth �1 _ Filler Material & Depth 0 t TYPE`OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION { I (No septic system permitted if public sewer is i available within 200 feet.l I ' Installation will,serve: Residence— Commercial_ yther Number of living units: _Number of bedrooms Character of soil to a depth of 3 feet: 1 Water table depth f SEPTIC TANK. ❑ TypelMfg! Capacity No. Compartments I PKG. TREATMENT PLT. ❑ P -rN ; Method of Disposal Distance to-nearest; Well —!—Foundation Property Line LEACHING LINE ❑ No. & Length of lines i Ce 0 tN Total length/size ` FILTER BED ❑ Distance to nearest: Well, Foundation Property Line SEEPAGE PITS 11 Depth Size i Number SUMPS [l Distance to nearest: Well t Foundation - Property Line DISPOSAL PONDS ❑ + I hereby certify that I have prepared this application and that the work will be done 1in,,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 followings"I certify that in the performance of the work for which this permit is issued, l 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 certify that in the performance of the work for which this;peimit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r t r The applican s all al re ire ins c 0n Complete drawing+on re erse side. t r r ff'Sec-Tres 6 July 90 „,.,,..Signed_. f wTitle Date: �� * a r•.�=- -....� ` �--" F. USE ONLY i Application Accepted by Date -0res Pit or Grout Inspection by Date .Final Inspection by Dated O Additional Comments: jApplicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER NO. tNFO !f « EH 13-24 1AEv,11"51 i EH 14.26 a