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APPLICATION ? �r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 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. 5.119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servicet3. ,1 - City i}—_- Lot Size/Acreage Job Address 15559_12�� Rd Owner's Mame Luchia Olivieri" Gri"1JAqdfe55 same Phonp31=_1-366 Clark Well' 2024 E . Charter Lgce^nse ❑371560 phone 462-7676 Contractor Address TYPE OF WELL/PUMP: NEW WELL C3WELL REPLACEMENT R DESTRUCTION Cl Out of Service W 1 0 ' PUMP INSTALLATION)EN SYSTEM REPAIR C7 OTHER G Monitoring Well O 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 Dia. of Well Casing (� Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation_ ` Type of Casio Specifications C1 Domestic/Private C1 Gravel Pack L7 Tracy 9-- I,, 11 Public f"1 Other I) Delta Depth of Grout Seal Type of Grout �•} 1 Irrigation . �_.Approx. Dep�i,�l,l Eastern Surface Seal Installed by Repair Work Done � ,E n Type of Pump g i n R_ Z'Uhl".A. �-,----- State Work Done d d e Well Destruction ❑ Well Diameter Sealing Xeterial k Depth „ w l 5o r'1 Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.l Installation will serve: Residence — Commercial _ Other 0 Number of living units: Number of bedrooms ' f Character of soil to a depth of 3 feet: ---_ - - __.._Water table depth 1 SEPTIC TANK ❑ . Type/Mfg Capacity _ No. Compartments PKG. 7REATMENf�.PLT, ❑` Method of Disposal C� Distance to nearest: Well Foundation Property Line h LEACHING LINE Cl No. & Length of lines Total length/size I' FILTER BED n Distance to nearest: Well Foundation Property Line {� SEEPAGE PITS I ] Depth Size - Number - SUMPS LI Distance to nearest: Well Foundation Property Line f .D15POSAL PONDS O k 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 Horne 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 ampipy 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 applican aft 1 ui m c Co lata drawing on reverse side. Signed K Title: Date: .L4- T n n P 1 9()3 DEPARTMENT USE ONLY Application Accepted by ! Pv s �r`1 Date 3 Area Pit or Grout Inspection by G/ C Data `Fined Inspection by _ Delo FAdditional Comments: I Applicant - Return all copi�s 'to San Jo quin County Public 1fe lth Services Environmental health Permit/Services Stk �•i7�el `fuP't 495 N San .TOagtrin, P O Box 2409, Stkn, CA 95241. ��J_f/ � u�� . ll -/6 -e,,& I/tlGr f r EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT No. tTjUiLw>� Lp INFO L/ �� / : H13-24(REV,I/m 13 w 6,0 o� 00 6 F r'1 S4.2b