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t ' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-5420 P 0 BOX 2009, STOCKTON, CA 95201 J!MIT EXPIRES 1 YEAR FROM DATE (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. 5149 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. JobAddress1 998 S. Harlan Rd CitpXenCh -g-=rLot Size/Acreage 11 Stuart' s ~ 982-0525 Nurser Address PO Box 241 Phone Owner's Name r Contractor Clark Well, Inc. Address 2024 E. Charter Way License No371 560 Phone 462-7676 l TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well L SYSTEM REPAIR ❑ OTHEFIXIRI Monitoring Well PUMP INSTALLATION ❑ r ; DISTANCE TO NEAREST: SEPTIC TANK 1 0 0 r SEWER LINES DISPOSAL FLD. PROP. LINE 2 5 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 400 r Err test well & E Log CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 6 Dia. of Well Casing)) )CkDomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications E I'I Public is Other fl Delta Depth of Grout Seal Type of Grout I I Irfigation ____ Approx. Depth I I Eastern Surface Seal installed by � e Repair Work Done 0 Type of Pump H.P. Stat or D e Well Destruction ❑ Well Diameter Sealing Material & Depth �� l Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence— Commerciat_ Other n i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t� SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal ' Distance to nearest: Well Foundation Property Line v LEACHING UNE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 taws, and\ rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the fallowing: "l 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." Contractors hiring at sub contracting signature certifies the following: "I certity that 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." r The applicant t f r ed inspections. Complete drawing on reverse side. I Signed x Title: VP Clark Well, Inc. Date: 26 Nov 90 f FOR DEPARTMENT USE ONLY . Application Accepted by Date yC7 Area 07/5, Pit or Grout Inspection by D,ate Fin I Inspection by Date Additional Comments: f Applicant - Return all copies to: San Joaquin County Public Health R! i Services, Environmental Health Permit/Services �irt/y/p6r rt 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 (J FEE I AMOUNT DUE AMOUNT REMITTED CA3 RECEIVED BY DATE PERMIT'NO. INFO + Eli 13.24(REV.It n 5) � EH 14.26 / 5