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r S APPLICATION R # o�o SAN JOAQUIN COUNTY; PUBLIC HEALTH SE ICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468— 4 � P O BOX 2009, STOCKTON, CA 952 FAC # PERMIT E%PIRES 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 desc �---� 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. . fv Job Address 14860 East Baker- ,Rd �' City- .Titi1 Lot Size/Acreage 48 owner's Name Arnold T o s o & Sons Address 5 0 3 0 N. Holman Phone476-0515 Contractor Clark Well , Tnc . Address 2024 E . Charter Way License No. 371560 Phone462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM'ENT'S DESTRUCTIONS Out of Service Well O PUMP INSTALLATIONK29 SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK +100 1 SEWER LINES DISPOSAL FLD.__ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER-WELL _ PITS/SUMPS -_ INTENDED USE TYPE OF WELL PROBLEM AREA e CON'.STRUCTION SPECIFICA Y16NS CI Industrial O Open Bottom 0 Manteca Dia. of'Well Excavation 1 1' Dia. of Well Casing 611 xkbDomestic/Private A.1 Gravel Pack O Tracy Type of Casing– AT r_, 16 t;. Specifications(;1 I"1 Public I1 9ther n Delta Depth of Grout Seal 1��t `I�� Type of Grou7B E I I Irrigation/.Approx. Depth I I Eastern Surface Seal Installed by C l a r k Repair Work Done U Type of Pump Sub H.P. 1 State Work Done- m n u a 7 Well Destruction O Well Diameter �11- Sealing Material & Depth � 9 S a C k Depth rateraDepth TYPE OF SEPTIC WORK:, NEW.INSTALLATION I I REPAIR/ADDITION I I- DESTRUCTION I I INo septic system permitted if public sewer is `1 1 available` itNn 200 feet.) Installation will server Residence_ Oommercial `Other Number of living units �ti"Nu`mber of bedrooms i 1 Character of_soil'to a depth of 3 feet: — '' =' eA Water table depth SEPTIC TANK,. O) 'Type/Mfg +` '` Capacity .t No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal -\Distance to nearest: Weli Foundation Property Line tf LEACHINd;LINE "�,...�t ❑ No. & Length of,lines ' Total length/size— ' FILTER BED ❑ "-Distance to neaiest 1Nell, Foundation Property Line SEEPAGE PITS i r `IIIA Depth , Size Number –SUMP S7% +'LI 'Distance to nearest: Well Foundation Property Linis DISPOSAL PONDS . O-- *4 - 1`?hereby.,cenifylthatsPhave'prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 7` rules and regulations of the San Joaquin County Home owner or' icensed 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 cenit Or ance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cali The applica I f I e ins eta drawing on reverse side. Signed X Title: VP C1.2rk, Well r 114 a _ Date:2 6 Aug 93 FOR DEPARTMENT USE ONLY Z A Application Accepted by Date rea Pit or rout nspection by Date o�inal Inspection b Date Additiona'I:Comrr+snts: rr Applicant - Return all copies to: San Joaquin ounty Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED Y DATE PERMIT'NO. q0 `70 Y17 EH 13-11.20 NIREV.�/Nsl�" v ' / / �� I/ `�/— �f✓ r ,�� l O " g36,9 EH