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Y , APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE P 0 BOX 2009, STOCKTON, C�;R#01 / PERMIT EXPIRES 1 YEAR FROMSSUED / (Complete in Tripli ate) Application is hereby made.to San Joaquin County for a permit to construcL%V!j' and his application is made in compliance with San Joaquin County Ordinance No. 5the Ruf and Regulations of an Joaquin County Public Health Services. PW8-76 MO Job Address 16777 S • Howland Cityof Size/Acreage owner's Name TreaTek Cra as Agents Address 2701 E . Hammer Phone 472-2020 Clark Well 2024 E . Charter WaXicense N0371560 Phone 462-7676 Contractor Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTXN DESTRUCTIC Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHI:rr LJ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 711 Dia. of Well Casing6 5 8 C.l Domestic/Private X{_1XCXavel Pack ❑ Tracy Type of CasingC r A a l Specifications 2 I'I Public (_1 Oth f FI Delta Depth of Grout Seal h Type of Grout Q SSC &&C I I Irrigation J_J(Approx. Depth I I Eastern Surface Seal Installed by _C I tE Repair Work Done LJ Type of Pump _ _ H.P. __-- State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION 1 1 (No 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK D 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 Cl Distance to nearest: Well Founaation 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 rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican c II r q e i ct' C pie drawing on reverse side. Signed X &01 Title: VP Clark Well Date: 16 Feb 94 FOR DEPARTMENT USE ONLY 7 /L Application Accepted by Date /7 f Area Pit or Grout Inspection byy/y�(- ante /Finall Inspection b /Date Additional Comments: 'I/ ��/ V —// J �O -33 / �G ��✓�f'G ems/ �+'//�J� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IF�EE AMOUNT DUE AMOUNT REMITTED C KSH RECEIVED BY DATE PERMIT NO. FO EN 13.7 (REV.rinsr 01 EH I4.26