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APPLICATION r�� Gam' s•�� - �� ty 0© DGo SAN JOAQUIN COUNTY PUBLIC HEALTH SE IC ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468— 4 P O BOX 2009, STOCKTON, CA 952 FAC# �"�--- PERMIT EXPIRES 1 YEAR FROM DATE I S (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein descr 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. Job Address 14860 East.• Baker Rd City Lot size/Acreage 48 JIB owner's Name Arnold Tioso & Sons Address 5030 N Holman Phone 476_ 051 Contractor Clark Well ], Inca Address 2024 E . Charter Way License No. 371560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM'ENT'S DESTRUCTIONx[R Out of Service Well ❑ PUMP!INSTALLATIONX® SYSTEM REPAIR ❑ OTHER O Monitoring WellU DISTANCE TO NEAREST: SEPTIC TANK +1 00 t SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIWIONS 4 n Industrial ❑ Open Bottom ❑ Manteca Dia. of'Well Excavation 1 2'r r Dia. of Well Casing 6t' I X l omestic/Private Gra vat Pack ❑ Tracy Type of Casing_ EVC Specifications( ' 69 I'1 Publicfa ther fl Delta Depth of Grout Seal 100 t Type of Groun 1- 1I Irrigation �.Approx. Depth 11 Eastern Surface Seal Installed by Clark Repair Work Done U Type o_f Pump S u h _ H.P. 1 _— State Work Done m n v a i I`' tt Sealing Material 6 Depth I > } ® 9 S a C k Well Destruction ❑ Well Diameter 6 _ —'� " A` Dept 1 1St I�(� F111er Material'& Depth TYPE OF SEPTIC WORK:. NEW INSTALLATION-I I REPAIR/ADDITION I I- DESTRUCTION I I INo septic system permitted if public sewer is 111 "i� available v ithin 200.feet.l :.. t Installation will serve: Residence_ t, ommercial Other Number of living unite= P� Number of bed oomsIt Character of,soil to a depth of. feel s r 11 Water table depth j. SEPTIC TANK 'Type/Mfg ' *�� Capacity No.Compartments ' PKG. TREATMENT PLT. C1 'Vi' "W - - Method of Disposal V Dis ' tance to nearest: ell _ Foundation Property Line ^ LEACHINGILINE -lam` N & Length of, n_es Total length/size FILTER BED O "Distance to,nearest.> , Well, Foundation Property Line SSEEPAGE PITS yt III Depth Size 1 Number UMPS 3 �LI 'Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑- _ 'have'prepaled this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 1�heretiy�certify that Id rules and'regulations'of the San'?Joaquin County' Home owner of 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 "in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person * certifies the following: "I certif or ante of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tI �`—tion•lows of Cali ia." ` The applica 1 f I ell ins ete drawing on reverse side. Signed !I Title: IT y r 1_2 r k til g l l T Date:2 6 Aug 93 FOR DEPARTMENT USE ONLY Application Accepted by Y Date Area Pit or rout inspection by lI Date ef�inal Inspection b Date g Additional Comments: Applicant - Return all copies to: San Joaquin ounty Public Health Services I Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IFEENFO AMOUN`DUE AMOUNT REMITTED CK RECEIVED Y DATE PERMIT'N1 ' . EMt3•NIREV.tiesi � U _ 3g 0 4!5't il!