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APPLICATION FOR PERMIT f0l 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 I 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 and the Rules and Regulations of. San Joaquin County Public Health Services. Job Address 4511 Pacific AveCityStockton Lot Size/Acreage Mr. Balwinder Brar Owner's Name Arco Mini Mart Address same Phone Contractor Clark Well TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO09COut of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS =A49W Address 2024 E. Charter Way License No. 371 560 Phon462-767 INTENDED USE ❑ Industrial Cl Domestic/ Private Il Public I I Irrigation Repair Work Done Well Destruction gest bores OF SEPTIC TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Total length/size FILTER BED ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia oL- II Casing _ I I ❑ Gravel Pack O Tracy Type of Casing Specifications ..–� Distance to nearest: Well [1 Other n Delta Depth of Grout S al Type o Grout —.Approx. Depth 1 I Eastern Surface Seal In tailed by U Type of Pump �_ H.P. State Work Done _ ❑ Well Diameter 4 Sealing Material & 11 pth Depth 16 t & 2 3 t Filler Material & Dep INSTALLATION I I REPAIR/A Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ DESTRUCTIOTf4_L.LNo septic system Water table depth _ Capacity No. Compartments Distance to nearest: Well Foundation Method of Disposal Property Line if public sewer is 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 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 persons subject to workman's compensa- tion laws of California." The applicantorgist co for,4l1_req ' ed j42ftctiog(. Cgmplete drawing on reverse side. Signed X/ 111MI'M //1 .� yam/ Title: VP Clark Well Date: 25 Feb 91 Application Accepted by Pit or Grout Inspection by Additional Comments: (" FOR DEPARTMENT USE ONLY .0 CAA .L`! 8��*.. Date Area 1,4 CL AA_ Date Final Inspection by AU ` Date Applicant – Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 a 13.24 (REV. I / n s 4 ;4.20 FEE AMOUNT DUE INF AMOUNT REMITTED I CK 11 CASH RECEIVED BY DATE PERMIT' NO.