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APPLICATION FOR PERMIT--^ -SAN��AQUI N COUNTY PUBLIC HEALTH 6.dRVICEST `� ENV IROMO NTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 f ED P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE I SU (Complete in Triplicate) Application is hereby made.to Ban 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 and the Rules and Re"tione of SAn Joaquin County Public Health Services. f Job Address 6374 E . J a h a n t Ci4C a m p o - _ Lot Si ze/Acreage _32 Owner's Name AddressPhone _169 1 262 Contractor Clark Well Address __2024 R_ ,Uart-Qr License No. 371 569 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION xq Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS . INTENDED USE TYPE OF,_WFt,L PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industria! ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia, of Well Casing f.l Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing_ Specifications I'1 Public I-1 Other f'1 Delta Depth of Grout Seal Type of Grout I I Irrigation ,_._.Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter it Sealing Material & Depth Sftnd t -35 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 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 Will to a depth of 3 feet: Water table depth SEPTIC TANK - 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PL7. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size 1> FILTER BED ❑ Distance to nearest: Well Foundation Propeny Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 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 stall employ persons subject to workman's compensa- tion laws of Cellfornia." The applica mu ca for I eq ins w . Complete drawing on reverse side. Signed Title: Date: - 1 3 A p r 23 FOR DEPARTMENT USE ONLY Application Accepted by �� Date ��/3 Area Pit or Grout Inspection b -� Y Date Fina) Inspection by Date Additional Comments: r Applicant - Returnall copies to: San Joaquin County Public Health ServicesIr Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 G FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH f I