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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 YEAR PM DATE ISSUM (Complete in Triplicate) Application 1s hereby inade,to San Joaquin County for a permit to construct end/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of San Joaquin County Public Health Services. Job Address x-•161 N. Hwy 99 City Stkn Lot Size/Acreage 1 /2 acre Will Forbes same 369-6398 Owner's Name Address Phone Contractor Clark Well, I;1c Address2024 E. Charter W� License No371 560 Phone 462-7676 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENTAR DESTRUCTION kkOut of Service Well 0 PUMP INSTALLATION t7 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK " 50 ' SEWER LINES DISPOSAL FLO. PROP. LINE 2-0-L FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS 1-00 r INTENDED USE TYPE OF WELT "PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia, of Well Casing 6 5 8�r XX Domestic/Private X® Gravel Pack , ❑ Tracy Type of Casing, St-P-01 L Specifications #I a M Public Cl Other ❑ Delta Depth of Grout Seal 1 00ft Type of Grout 9 Sack G Irrigation 200 r Approx• Depth ❑ Eastern Surface Seal Installed by Clark Repair Work Done 0 Type of Pump 51L H.P. State Work Done 1110-ye.-D MP Well .Destruction V Well Diameter 6"_ Sealing Material s'Depth 130 ' f ' sand Depth 13 0 _ Filler Material i Depth f ground TYPE OF SEPTIC WORK: NEW INSTALLATION L3 REPAtRIADOITION 0 DESTRUCTION G INo septic system permitted if public sewer is available within 200 feet.l 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 PKG. TREATMENT PLT. G1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line ...E SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line f DISPOSAL PONDS ❑ I 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 workman's compensation laws of California." Contractor's hiring of 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." i The applicant sl all fa al au' d io s, Complete drawing on reverse side. _ "� Signed Title: VP Clark Well , Inc Date: 8 Jan 91 i FOR DEPARTMENT USE ONLY „ Applica ' Accepted by _ Date �" �i Area { Pito Gro Inspection by DaleFinal Inspection b:`s_ Date Additional Comments: ��O ` /� Z �S( tl d ^d d-1 fL, Applicant - Return all copies to: SAN JOAQU COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK f CASH FIECEIVEO BY DATE PERMIT NO. 2 (�• . CH 13.24 Italy,rives, ' i O -CD D k I-Oa 44