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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION , 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 AERNIT EXPIRES 1 YEAR FR_0h DATE ISQUED (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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 560 E. LDUI SL Job Address SE Corner T n i, i g e R, C Q M h r i rl n c City La Y h r n p - Lot Size/Acreage _10 acres Owner's Name L'0F Address 500 E. Louise Phone 858-5151 Contractor(C1 ark Wad 1 Address License No.371 56Q___ _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONXg.0ut of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1: Domestic/Private ❑ Gravel Pack 11 Tracy Type of Casing Specifications FI Public C] Other n Delta Depth of Grout Seal Type of Grout G I I Irrigation ____Approx. Depth I I Eastern Surface Seal Installed by d Repair Work Dona L7 Type of Pump H.P. State Work Done Well Destruction- k7 Well Diameter J 4 Sealing Material & Depth 4 qq r o t o p Depth g _ Filler Material & Depth:- ' :; 'OTMO P` TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments l PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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 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 workmen'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 applican s call or re in ns. late drawing on reverse side. Signed X Title: VP_ Clark Well , T n r- Date: 27 .Tan 93__— �` FOR DEPARTMENT USE ONLY Application Accepted by �1•Ae,�-'tl��t��(� 11 2Q MA& Date � A Ik Area Pit or Grout Inspection by Date Final Inspection by Date 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 OUNT DUE AMOUNT REMITTED �JC�� RECEIVED BY If DATE EINFO ASN PERMiT NO. _DL �3JZEH 1i. 1REV. i x si 0 © � V� //