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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 FMDTE 5 <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address CityLathro Lot Size/Acreage <br /> Owner's Name LOF Address <br /> Phone <br /> Contractor Clark Well Addres?S024 E. Charter Way 371560 462-7676 <br /> License No. � Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service We ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR p OTHER ❑ Monitoring well O <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELI PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'1 Public C1 Other n Delta Depth of Grout Seat Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Wolf Destruction XQ Well Diameter 1 6, � Sealing Material it Depth to But <br /> Depth I 68.L_ Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION I I (NO se tics stem k{sand & ce nt) <br /> - P Y permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will carve: Residents— Commercial" Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK <br /> Water table depth <br /> ❑ Typs/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal Q <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire <br /> Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> N <br /> 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 J L <br /> rules and regulations of the Sen Joaquin County <br /> 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 <br /> certifies the following <br /> employ any person g such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> tion laws of California.": "I unify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> The applican t c II r r r► io Complete Browing on reverse side. <br /> Signed Title: <br /> Date: 21��.>r 91 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by G� ,I <br /> Date ea �+ �c - <br /> Pit or Grout Inspection by Date Final Inspection b <br /> Data <br /> Additional Comments; <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 H San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO C SH RECEIVED By DATE PERMIT'NO. <br /> EN 13.24 Jft9V.(real uA1 e l rS7 <br /> ,EN 14•m �V � <br />