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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 P &RMIT EXPIRES 1 YFiAR rROM ,PATE 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 made in camwliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of flan Joaquin County Public Health Services. Pre-72 Lot. Of Recc Job Address 10364 N Jack Tone City Stkn Lot Size/Acreage +50 acres Jack Plotz same 931 -3730 Owner's Name Address Phone Contractor Clark Well, Inc Address2024 E. Charter License No. 371 560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ?.�X DESTRUCTIONNYOut of Service Well Cl PUMP INSTALLATIONS SYSTEM REPAIR 0 OTHER ❑ Monitoring Well E1 DISTANCE TO NEAREST: SEPTIC TANK 90 , SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL— PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing 8 5/811 XX15 Domestic/Private Xyl Grave! Pack ❑ Tracy Type of Casing Steel Specifications .- 15 6 M Public Ia Other ❑ Delta Depth of Grout Seat 50 ' Type of Grouts Sack _ Cl irrigation A Clark U _Approx. Depth d Eastern Surface Seal Installed by Repair Work Done (J Type of Pump _Sub H.P, 2 State Work Done move from Well to new W Well Destruction ❑ Well Diameter Err Sealing Material i Depth �f; l t•,,,ttem 4_9 top 6 sack Depth app 140 ' Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIRIADDITION M DESTRUCTION M (No septic system permitted if public sewer is W available within 200}eat.l installation will sere: Residence__._, Commercial— Other Number of living units: Number of bedrooms Character of taoil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size {7. FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Sue Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sar+ Joaquin county Home owner or licensed agent's signature certifies the loliowing: "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 Calif rnla." The applicant u c I for 7qet tions, ompl a drawing on reverse side. Signed X. Title,• VP Clark Well, Inc _ Date: 8 Mar 91 OR DEPARTMENT USE ONLY cl Application Accepted by Date 3— 5—Are, Pit orro t Inspection by Date 1 qZ Fine Inspection by'Z—� Additional Comments: Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES T 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY DATE PERMITNO. + EH A-26 EH 13-241REV.rinyl 04 (j ys„_ Is . <Z C11 �Jrw1