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* APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH. SERVICES ENVIRONMEN'T'AL HEALTH DIVISION ! 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 P,, WIT EXPIRES 1 YEAR FRPM DATE „ISSUED (Complete in Triplicate) Application is hereby made to $an Joaquin County for a permit to construct and/or install the York herein described. This application is made in compliance vith San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4932 Shippee' Lane n Stk City Lot Size/Acreage'-1 . 5 Owner's Name Helen Wilson Address Phone same 931 -1121 Contractor Clark Address 2024 E. Charter License No.371560 Phone 462-7676 _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTXX DESTRUCTIONK0 Out of Service Well ❑ PUMP INSTALLATION-]�X SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK q7 r — SEWER LINES DISPOSAL FLD. PROP. LINE -- FOUNDATION AGRICULTURE WELL OTHER WELL 50 _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 2rr ++. Dia. of Well Casing A3[Domestic/Private (34kravel Pack ❑ Tracy Type of Casing i'1 Public Specifications.P�,.�� C] Other . . n Delta Depth of Grout Seal -1-0 Type Type of Grout I f Irrigation _ Approx. Depth I I Eastern Surface Soul Installed by Clark Repair Work Done L3 Type of Pump.-SlIbL _ H.P. State Work Done_mnvQ �., nac, toll Well Destruction P9X Well Diameter 6: 11 Sealing Material & Depth _ ] f)�t+r pnZjf- T�i1;,= Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is , Installation will serve: Residence Commercial available within 200 feet.) _ Other Number.of living units: Number of bedrooms Character of soil to ti depth of 3 fleet: Water table depth t SEPTIC TANK: ❑ Type/Mfg ; PKG. TREATMENT PLT. ❑ Capacit Y No. Compartments f Method of Disposal Distance to nearest: Well Foundation = Property Line LEACHING LINE D No. &=Length of lines Total length/size r FILTER BED Cl Distance to'nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire N umber w � SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 �r 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 r 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,`l shall net *� 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 cerci 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 Californi ' The applicant at r II uir spec ions. Complete drawing on reverse side. Signed X Titte:Clark Well Date: - 2 7 Aug90 FOR DEPARTMENT USE ONLY Application Accepted by a& Dare "-9( Area Pit or Grout Inspection by Dat 1 Fina nspection by f /d� 9U �' Da � Additions! Comments: 0 Applicant - Return all copies to: San Joaquin County Public Health �-363 C(d Services, Environmental Health Permit/Services tt/'p r 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 9 201FEE INFO MOUNT DUE AMO T REMITTED CX RECEIVED BY CASH DATE PERMIT'N0. 111 . EH13-15{REV.rinsl {3 r,� EH��-TB _ Y t o- 2 �7 1 e2 A cA I