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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 �.� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 trade in Compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 95346 S. Kal�ain cityLa, .hrtop Lot Size/Acreage Owner's Narn a"2 0-e'l! R. C O to Address Phone _ 8 3 Contractor Cla2k I iX_e, Inc Address 2024 License No.3 7 7 5 f)--Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION)E-*t of Service Well 0 PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r\ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f7 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications ` I, I'l Public I.1 Other n Delta Depth of Grout Seal Type of Grout �J�} I I Irrigation — Approx. Depth [I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 611 Sealing Material A Depth Om jo .f.o/2 Depth "n k n n t!Zrd:�� Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is 1 ,� available within 200 feet.l +`J] Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to s depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. L) Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED [_l Distance to nearest; Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L3 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 laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "i certify that in the performance of the work for which this permit is issued, I shall not employ any person in such[Wanner 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 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant nnor 11 it pe i mple drawing on reverse side. Signed X Title: 11 Uan_k Inc Date: 9 Sep 92 FO ENT USE ONLYAM �{ Application Accepted by AA Date 1 �` Area Pit or Grout Inspection by Data Final Inspection b Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K A INFO Af CEIyED iEIY ATE PERMI7'NO. EH 19.20 IRIN.I/IM W� 1 EM 1f'•2tl