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f, APPLICATION SAN' JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f 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. Joh Address 5235 East Carpenter City Stkn Lot Size/Acreage 5 acres Betty SkaggsAddress same Phone 464-3195 Owner's Name - . - ractus Clark Well Address 2024 E . Charter License No, 371560 Phone 4627676 Cont TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Cl Out of service Well ❑ OTHER ❑ Monitoring well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK r Cn f- SEWER LINES DISPOSAL FLD, PROP. LINE �_ FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tr n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation—1 r Dia. of Well Casing ravel Pack ❑ Tracy Type of Casin t o 0 1 Specifications ._ 7 9L ^..^^o gR Domestic/Private x PxG g- I'I Public5235 r Type of Grout __4 2 3 u1SOther� �' 17 t pn Delta Depth of Grout SeaIP 9r= �G -- I i Irrigation Approx. Depth i I Eastern Surface Seal Installed by Repair Work Don-p,e P1 y Tyge,of f-mp H"P. �„- - State Work Done ti A- i S Well Destruction ❑ Well Diameter Sealing Material r4 Depth (� Filler Material,& Depth L 6 2 7 6 7 6 � \1 {: Qepth j i s n a 1 e , TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIR/ADDITION I 1 DESTRUCTION I I lNo sbelrwihin m rented if public sewer is Installation will serve: Residence_ Commercial— Other Number of living units: Number of be&Aio ns Character of soil to a depth of 3 feet: Wei table depth SEPTIC TANK ❑ Type/Mfg Nit No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r' x�,Oistance to nearest: ;I�L 41 1Cl' G A'i 9pperty Line 10 g t a g e X X s being completeda`r LEACHING LINEµ ❑ No. & Length of iinesWow FILTER BED 0 Distance to nearest: b��F"� �$�of'operty Line f 4"" B e 1.i Y�c.Zce J i SEEPAGE PITS i-I depth Siler6 Number E1 SUMPS LI Distance to nearest: Well Foundation Property Line 1 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- �l 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." Z �' 5, Si r The applicant c 1 fob F L j ire 10 . Co plate drawing on reverse side. �,r ; 0ua�e y Signed X Title: L[ 1' Date: FO DEPARTMENT USE ONLY Application Accepted by t Date - Area_ 02 J 9 Pit or Grout Inspec'ti�y Date 1 Final inspectionDate r Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK R ECEIVED BY D "T£ PERMIT"NO. y INFO �� } EH 1324.IREV.l i n 61 EllV Q aD 3 �_ EH 4-25 r V? U I a.T k w C .�. `1:1Y C J 1 F�" .r �3 i —