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APPLICATION FOR PERMIT SAN AQUIN COUNTY PUBLIC HEALTH SERV O J ICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , 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 compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. JobAddress10998 S Harlan Rd CittFrPnch CaDrLot Size/Acreage 11 Owner's Name Stuart' s Nursery Address PO Box 241 Phona982-0525 Contractor Clark Well, Inc. Address 2024 E. Charter Way License no,371 560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERKO Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 10 0 SEWER LINES DISPOSAL FLD. PROP. LINE 25 ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 400 ' 6" test Well & E Lt* ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 6 Dia. of Well Casingn 7CkDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. Statg 1(JorkiD e Well Destruction ❑ Well Diameter Sealing Material i Depth �(✓H/ <1 /I! r`P G Q �! S Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sower is N l available within 200 feel.) Installation will serve: Residence_ Commercial_ Other �O^ Number of living units: _ Number of bedrooms q�> Character of soil 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 employ persona subject to workman's compensa- tion laws of California." The applicant t 1 r tied inspections. Complete drawing on reverse side. Signed Title: VP Clark Well, Incl. Date: 26 Nov 90 FOR DEPARTMENT USE ONLY Application Accepted by � ,�aUtyDateArea /� O Pit or Grout Inspection byDate Fin I Inspection by Date Additional Comments: ,Z; Applicant - Return all copies to: San Joaquin County Public Health w 114 Services, Environmental Health Permit/Services ✓� V 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO P CASH . EN 13211REV.,/.So VE I � r�- `�/ EH 142a V