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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 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR 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 ccwliance with San Joaquin County Ordinance No. 549 and 2$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 11418 Comstock Rd City Linden Lot, size/Acreage Owner's Name L 11 C h i x3-01 i V i P r i O r i .i Iddress _l S S S Q Comstock RdPhone - Contractor Clark Well Address 2024 E. Charter License No.171560 Phone 462-7676 TYPE Of WELL/PUMP= NEW WELL ❑ WELL AEPLACEMENT ❑ DESTRUCTl0l*R1x0ut of Bervioe Yell PUMP INSTALLATION ❑ SYSTEM REPAIR L] OTHER O Monitoring well O DISTANCE TO NEAREST: SEPTIC TANK SEWEA LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Web Excavation Dia_of Well Casing r] Domastielprivate ❑ Gravel Pack O Tracy Type of Casing Specifications i'1 Public fl Other n Delta Depth of Grout Seal Type of Grout i 1 Irrigation —Approx. Depth I I Eastern Surface Seat Installed by Repan Work Dans U Type of Pump H.P. State Work Done _ Well Destruction 0 Well DiameterrRA!X-7w-sealing Material 0 DepthF144.4. bot�uiu to tup a c k Depth a p p Y&err /®d Filler Material i Depth .tea & 9 0memb _ l� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I tNo septic system parrnilied it public sewer is available within 200 feet.l Installation will serve: Residence� Commercial_ Other Numbw of living units: Number of bedrooms Character of soil to a depth of 3 fort: Water table depth SEPTIC TANK, 0 Typa/Mfg Capacity No. Compartments PKC.TREATMENT PLT.d Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LI No.&Length of Iknes Total length/size FILTER BED D Distance to nearest: Wall Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS UI Distance to nearest: Well Foundation, Property Line DISPOSAL PONDS ❑ I hereby corldv 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 raguletions 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 ertplOy any person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or sub-Contracting signature certnifts the following:"I certify a P performanca of the work for which this permit is Issued,I shall employ parsons subject to workman's compensa- tion taws of for is." The r i ions. Complete drawing on reveraa side. SionedX-, ..� T;�VP Clark Well Date: 1414 July 93 FO DEP TIMENT USE ONLY Application Accepted by r Data A,. Pk Or Grout Impaction by Date F'yiai Inspection by Date Additional Comments. t C GCSeza- Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health 0 Box 2009, Sts 495 N ban Joaquin, P O Boz 2009, Sutra, CA 952 tJ EINF-0 AMOUNT DuE AMOUNT REMITTED C N RECEN 8Y DATE rs f] JJ. • EN 1.2-'ll tt1EV.1 t M1 61 EN f4Za " �"'�!