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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONES (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR R 1M DATE MUM (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 cowliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address C n�_umhsia_was i�l i n 7 - R Wo r—L hb City S k p _ __ Lot Size/Acreage ' L(?—0-'TO 12— Owner's ZOwner's Name City of Stnckt.nn Address City Hall Phone 944-8250 Contractor Clark Well . Inc Address 2024 E _ Chart Pr Way—License No.371560 Phone-2676 TYPE OF WELL/PUMA: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTIONxQ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well n 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I'1 Public C7 Other (I Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done_ Well Destruction XQ x Well Diameter 4 0 It Sealing Material E Depth Depth - - n3 ' filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I t iNo 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 foot: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments (�(1 PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L-) No. 8 Length of lines Total length/size FILTER BED 0 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 O 1 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 parson 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 coni t in the performance of the work for which this permit is issued, I shall employ persons subject to workman's Compensa- tion laws of Califom The appan s 11 licf M r n mplete drawing on reverse side. Signed Title: V P Date: 28 Apr 93 C FOR EPARTMENT USE ONLY Application Accepted by Date _:;4_ 3 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: Ban Joaquin County Public Health Services logy�r Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201FEE 7 INFO AMOUNT DUE AMOUNT REMITTED BM RECEIVED BY DATE PERMIT'N0. . EH ts.s4 trtEv.,,Rs,wo U �o EH t4•all