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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 EXP RES 1 YEAR FROM A E ED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This appllcatioa is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules LOdRegulations of San Joaquin County Public Health Services. 8151 Helen Lanecity Stkn Lot Size/Acreage Pre-72 Job Address Owner's Name Robert Falkner Address same Phone Contractor Clark Well, Inc Address 2024 E. CHarter License No. 37� 1 560—Phone 4627676 NEW WELL ❑ WELL REPLACEMENT XX DESTRUCTIONXiX Out of Service well ❑ TYPE OF WELL/PUMP. OTHER ❑ Monitoring Well ❑ PUMP INSTALLATION Cf] SYSTEM REPAIR D+100 30 r PROP. Lf 100 ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL ILD. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6+r Dia. of Well Casing n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �— Stel Specifications i r X�=�I�FomesticlPrivate gavel Peck C7 Tracy Type of Casing—Steel I'1 Public f:1 Other 11 Delta Depth of Grout Seal 100 , Type of Grout�!?T't I I Irrigation 225_Approx. Depth I I Eastern surface Seal Installed by Sub H.P, 3 State Work Done— MOVe Repair Work Done Type of Pump � Well Destruction 0 Well Diameter 6 sealing Material & Depth 1 1 7 f J 1 1 witll-1.3janJtonite Mediu Depth ---i1 7 p ' Filler Material & Depth bottom to tom t" TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I lNoseptic system hin m emitted if public seweravailable is Installation will serve: Residence— Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEP TANK. ❑ type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 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 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 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." Theapplicant ust all f re ui s ctio S. omplete drawing on reverse side. SignedI. Title: VP Date: 14 Feb 91 OR DEPARTMENT USE ONLY Application Accepted by r y Date Area Pit or Grout Inspection by { -- Date Final Inspection by Date Z � Additional Comments: Applicant — 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT ND. INFOua a EH 13.24 MEV.I/n s) ] l t3 t� •�� -�� EH 11.213