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APPLICATION FOR PERMIT r. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 with San Joaquin County Ordinance No. 549 and 1862 end the Rules and Regulations of San Joaquin County Public Health Services. Job Address10998 S. Harlan Rd CitlFrench CamrLot size/Acreag43. 11 Owner's Name Stuart' s Nursery Address PO Box 241 Phone982-0525 V Contractor Clark Well, Inc . Address 2024 E. Charter Way License No.371 560 Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEFPCZ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 10 0 SEWER LINES DISPOSAL FLD. PROP. LINE 25 ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 400 ' 6" t2St Well & E Lo C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 6 Dia. of Well Casingn a X3COomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Il Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout 0 I I Irrigation _.Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. Siatq {Jori D ne X A Well Destruction ❑ Well Diameter Sealing Material & Depth /vf%/ Iii Yt G -L1d" f"I Lj f a• Depth Filler Material & Depth 7 d/ ve .I' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is . available within 200 feet.) X Installation will some: Residence_ Commercial_ Other G �^ Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth �h SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �. PKG. TREATMENT PLL ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ 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 ❑ 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 v' 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 signatureV certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." ' The applicant t f 1�, red inspections. Complete drawing on reverse side. Signed X Title: VP Clark Well, Inc. Date: 26 Nov 90 ,.. FOR DEPARTMENT USE ONLY p Application Accepted by / }! '�"`� Date / U Area Pit or Grout Inspection by Date Firi ll Inspection by Date n Additional Comments: L� Applicant - Return all copies to: San Joaquin County Public Health , .nt`l� (gJ�"I,�sc', %'itR %h •'dy ` Services, Environmental Health Permit/Services:,/ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE r INFO AMOUNT DUE AMOUNT REMITTED / CASH RECEIVED BY DATE PERMITNO. EH 13 24 1 r N 51 EH 5 ... `? a4e ��