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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 4 AFiMIT MIRES 1 YEAR jSSUED (Complete in Triplicate) Application is hereby twsde to 5na Joaquin County for a permit to construct sad/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 Ser`ices. Pre-72 S u b d i v i s o n r Job Address ._ 7708 N • Pershing _ City S t o c k t o n -Lot Size/Acreage _ 1 /4 IDave & Karen Murry Address same Phone 952-8052 1 Owner's Name 11 ContractorClark Well Inc . Address 2024 E . Charter License No.371560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTXER DESTRUCTION ❑ Out or Service Well ❑ PUMP INSTALLATION� SYSTEM REPAIR l7 OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK -}�..._.. SEWER LINES DISPOSAL FLD,' PROP. LINE 15 r ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 tr C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welt Casing Xff Domestic/Private Travel Pack 0 Tracy Type of Casing Steel — Specifications M Public I'1 Other ❑ Delta Depth of Grout Seal 100 r -- Type of Grout� s a c k Cl Irrigation —..Approxi Depth ED Eastern Surface Seal installed by ' S,�h H.P. State Work Done — i n at-all Repair Work Done U Type of Pump Well Destruction ❑ Well Diameter Sealing Materiali Depth i Depth f Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION'❑ REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if pubiic sewer is C' available within 200 feet.) Dq installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet f Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 � Method of Disposal d Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size Z FILTER BED n Distance to nearest: Well Foundation Property Line (, SEEPAGE PITS l I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line } DISPOSAL PONDS O 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 4 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 smpioy persons subject to workman's compensa- tion laws of California." r l The applicant must ca or qutred inspections. Complete drawing on reverse side. ,1/,j� ,I • VP 1 ark Well Inc . laate:5-15-91 Signed % Title. - -- f FO DEPARTMENT USE ONLY Application Accepted by r, A Date _ .Area��-- Pit or Grout Inspection by LJADate l7 q Final Inspection by Date 6 k Additional Comments: fit , C'I&LA IG ` O a '-t Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEAL4H SE ICES + q ` ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ' 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 85201 FEE OUNT Dl1E RMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO. INFO . 114'2{IREV.+iNSI X12 EM EH 1{•20 1