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g II li APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION ! 1601 E. HAZELTON AVE. , PHONE (209)468-3420 11 P 0 BOX 2009, STOCKTON, CA 95201 i i PERMIT EXPIRES 1 YEAR FROM_DAT,9 ISSUED i (Complete in Triplicate) Application in hereby made.lto 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. U Job Address 9715 Leland City gi-nC -Fnn- Got Size/Acreage pr(4 72 � ii Owner's NameMarvin Backues Address same Phone ContractorClark Well,°![Inc. Address2024 E. Charter WaY License No371 5F(l Phone462-7676 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTX[R DESTRUCTION ❑ Out of Service Wel]. ❑ PUMP,.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 65 r SEWER LINES DISPOSAL FLD. PROP. LINE 21-L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i_211 Dia. of Well Casing rt )6A Domestic/Private RikGravel Pack ❑ Tracy Type of Casing PVC Specifications C3 2.QQ.� FI Public to Other n Delta Depth of Grout Seal 1 U r Type of Groutgpptipini 1--e — ,p + I Irrigation _ Approx, Depth I I Eastern Surface Seal Installed by�ner Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth I Depthl: Filler Material & Depth k TYPE OF SEPTIC WORK: NEWANSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION t I (No septic system permitted if public sewer is �� f I' available within 200 feet.) 1 Installation will serve: Residence_ Commercial— Other Number of living units: i� Number of bedrooms' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ it Method of Disposal r Distance to nearest: Well Foundation Property Line ;I LEACHING LINE ❑ No:I& Length of lines Total length/size i FILTER BEA D Distance to nearest: Well Foundation Property Line .i SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation _ Property Line DISPOSAL PONDS I-) II 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion taws of California." The applicant bit r 6' i ion Complete drawing on reverse side. Signed XZ 4 Title: VP--Clark Well, Inc. T Date: _ 27-_Sept_90 I� FO EPARTMENT USE ONLY l f. 'Application Accepted by Date�/_: Area ` Pit or Grout inspection by 'I `� Date �_IP114k Final Inspection by. '. -QZ69.YN Date 1-61140 Additional Comments: C��' r/a /�- Y GL h.1 Applicant - Return all copies to: San Jos in County Public Health Services, Environmental Health Permit/Services y i� 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 } INFO AMOUNT'.OVE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMI7'NO. i a EH t3-24 iREV.I/R51 II Eft 1{-26 � `l/z5 Q �� i