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APPLICATION- FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 XEM FROM DATE 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 cosilisnee with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Jab Addressl 904 C g 4 4 y y C 4!;A h, City GS+�n� Lot Size/Acreage Owner's Name B Address Phone 941 —1 526 Contractor Clark Well Address _ 2024 E,..--Charter License.No37156Q_____Phone AL 2—7 6 7 TYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOI*klxOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 ` 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing— Specifications l'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigation „--Approxi Depth l I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction Ck Well Diameter 411 sealing Material i Depth _Z-i-I I b o-�;�i 0 R, 4i E, P Depth 2 r Filler Hsterial i Depth Beiatopitia Lal 319-" TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 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 SON 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. 8 Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line j 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 Homo 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 Californis." Contractor's hiring or sub-contracting signature mortifies the following: "I certify t ormance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laves of Calif Dia." The applicant t all r Complete drawing on reverse side. Signed Title: Date: 26 r; 7 03_ i FO -ONLY Application Accepted by CVS 4y?a` _ ,e Data Area Pit or Grout Inspection by Date Final Inspection by Date yr Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 PEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO • EN 3-24 EH 1424 IREV.I i K 51