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k APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES { ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 ! P 0 BOR 2009, STOCKTON, CA 95201 LEWIT- EXPJRES 1 YEAR FROM DATE ISSUED i (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. I Job Address 5209 Shippee Lane City Stockton Lot Size/Acreage Owner's Name Greg Skeelsk Address 520-_ Shippee Lane ?bona Contractor Clark Well, Inc. Address 2024 E Charter 'Wa License No.371�60 _Phone 46 -7676 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We.I1 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C7 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT O_N_S n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [1 !f 3(Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing ?UG Specifications I'1 Public tK Other F1 Delta Depth of Grout Seal lot' Uation I — Type of Grout O�1 I i Irri .,Depth I I Eastern Suface Seal Installed by Repair Work Done 0 Type of Pum �t�ii I 1� _ l� 1, P yp p __S.� O H.P. �,• L' State Work Done—IN i��VV Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial_._- Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: # Water table depth SEPTIC TANK.,. # ❑ Type/Mfg ' "�' "Capacrt}i�'�'�"""" No."Campartments PKG. TREATMENT•PLT . Cl 1; Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE 0 No. & Lerfgth of lines Total length/size FILTER BED } Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS a I i Depth' s Size Number 1 SUMPS CI Distance to nearest: Well ' Foundation Property Line DISPOSAL PONDS p r r I hereby ce rfy t at I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and r gulat! ns of the San Joaquin.County Home ow ar or!i an$ad a t'a signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ w pers n in such ner as to me subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature an certifies the oil ing: "f c if t tin Orman of the work-for.which this permit!s issued, I shall employ persons subject to workman's compensa- tion laws of f !a.,, �f The applic t I r a r Ora in ct' s, mplete drawing on reverse side. (/ I Signed. . —Date: R DEPARTMENT USE ONLY Application Accepted by6 Date Z "� �_ Ares Pit or Grout inspection by ? ' Date �T Z � Final Inspection by Date 3I C, a Additional Comments: 3 Applicant - Return all copies to: San Joaq 1n County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE CK I INFO AMOU T D # AMOUNT REMITTED CASH RECEIVED BY DATE PERMtT'NO. . EH 14-24 IAEV.1/,4 51 1 EH i{•2a i