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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 11601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOR 2009, STOCKTON, CA 95201 '. PERMIT EXPIRES 1 -YEAR FRAM DATA ISSUED (Complete in Triplicate) CApplication is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This I application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San 1 Joaquin County Public Health Services. Job Address City Lath r Lot Size/Acreage -?o Owner's Name We S tpac Pacific Address same Phon — Contractor Clark Well, Inc Address 2Q24 F_ Chart-PT---- License No,?71 560 Phone TYRE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO*jd Out of Service Well ❑ r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ *, I IL 'DISTANCE TO NEAREST; SEPTIC TANK ! SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS •INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F'),Industrial ❑ Open Bottom I ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I') Public 1-1 Other I Cl,Delta — Depth'drGiout Sea],,` %Type of Grout f1 t .._.�• _. d� I I Irnbatian �Approx, Depth l'I'.Eastem�� Surface Seal installed by Repair Work Done U Type of'Pump I H.P. State Work Done _ Well Destruction Well Diameter 6 Sealing Material & Depth 1 F. .t, '_IRA4-- --RFR to tOp � Depth'"; .j3 3 Filler Material &;Depth 1 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION l l DESTRUCTION i I (No septic system permitted if public sewer is Iti' ! 1 01-0 ' i available".within 200 feet.) Installation will serve: Residence,'_= Commercial_ Other Number of living units: Number of bedrooms i r Character of soil to a depth of 3 feet: I ' Water table depth SEPTIC TANK ❑ Type/Mfg 1. '- Capacity No. Compartments PKG. TREATMENT PLT. Cl •' -� ! + Method of Disposal " Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No:&'Le+gth.of lines Total length/size yFILTER BED 0Dista a�1 to nearest: Well Foundation Property Line J F SEEPAGE PITS 11 Depth _ Size Number I+ SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I t 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 l 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 persona subject to workman's compensa- tion laws of California." I The applican�all I r e s s, ons Complete drawing onreverse side. Signed X Title: VP Clark Well Date: 30 Oct 90 e (PQR DEPARTMENT USE ONLY C y Application Accepted by (l.w.. �A t �9J - -- Date `� Area 4L1 ' Pit or Grout Inspection by • Date Final Inspection by Datt�O Additional Comments: j t Applicant ^ Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P O Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE f AMOUNT REMITTED CASH RECEIVED BY DATE C PERM4TI'N{O�. . EH 1124IREV.4/N51 I,e.Q,t'�f LV lD ��•'p( l.J� EH 11.21! s .