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- -- t APPLICATION <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTHI CE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468- <br /> SE <br /> 4 � <br /> P O BOX 2009, STOCKTON, CA 952 FAC �t <br /> PERMIT E%PIRES 1 YEAR FROM DATE I S it <br /> (Complete in Triplicate) <br /> st <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or inall the work herein desc <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. -r,)-" ;r - f <br /> 14860 East Baker 'Rd City '-gTij A__f-- Lot Size/Acreage 48 <br /> Job Address - <br /> owner's Name Arnold Toso & Sons Address 5030 N 1.. Holman Phone 476_ <br /> 0515 <br /> Contractor Clark Well , Inca Address 2024 E . Charter_ Way License No. 371560 Phone462-7676 <br /> TYPE OF WELL/PUMP: NEW WELL O - WELL REPLACEMENT- DESTRUCTIONx(R Out of Service Well O <br /> PUMP INSTALLATIONKIN SYSTEM REPAIR O OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK +1 nn 1 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA ,CONSTRUCTION SPECIFICAYIONS <br /> n Industrial O Open Bottom 0 Manteca „~Dia. of'Well Excavation 1 7`1 Dia. of Well Casing 611 <br /> x RINDomestic/Private )a Gravel Pack O Tracy Type of Casing- $V c r y , Specifications(; <br /> I'l Public I1 9ther n Delta Depth of Grout Seal 1 ' �o , , Type of GrOU9 SE}t <br /> I I Irrigation ;f .Approx. Depth I I Eastern Surface Seal Installed by r C1 ark' <br /> Repair Work Done 0 Type of Pump - Sub-- H.P. 1 __ State Work Done m ny e <br /> Sealing Material & Depth 1; t t i,„r=; <br /> Well Destruction O Well Diameter 11 / S - effi 1=e--:6-a1�--9 s a c k <br /> As Depth 5 Filler Material'& Depth ''} �✓ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOI I REPAIR/ADDITION I I- DESTRUCTION I I (No septic system permitted if public sewer is <br /> �s xi; `. available v�ithin 200 feet.) <br /> Installation will serve: Residence_ `Commercial Other <br /> Number of living units-�t "�` Number of bedrooms+ 1 <br /> Character of,soil to.a depth of 3 feet: � * t' Water table depth <br /> SEPTIC TANK 'Or Type/Mfg L. _- ' Capacity No: Compartments, (� <br /> i PKG. TREATMENT PLT.-O " _ -Method of Disposal <br /> �5Distance to nearest: 'Well Foundation Property Line <br /> l� LEACHING1LINE ": •fit Cl No. & Length of,lines r k Total length/size (� <br /> i FILTER BED \ O "'Distance totnearest:t ;Well', Foundation Property Line \� <br /> t. SEEPAGE�PFTS ; `Itl Depth Size " Number <br /> , <br /> SUMPS,"\ � � "LIQ"Distance to nearest. Well Foundation Property Line <br /> DISPOSAL PONDS . Cl•-- <br /> I/hereby.`certify t40I"have prepated this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and'regulations`of the San Joaquin County _ <br /> Home owner orlicensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> " employ any person'in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br />�* certifies the following: "I certif r t r ance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> '*�ticn.taws ofCali is 11 <br /> The applica 1 f I Ins ete drawing on reverse side. <br /> Signed Title: ILP C 1-2 r-k Wei I in Q Date:2 6 Aug 93 <br /> FOR DEPARTMENT USE ONLY <br /> ~ Date �- Area <br /> Application Accepted by <br /> Pit or rout nspection by Date 4Z/7q&nal Inspection b Date <br /> Additional Comrrlsnts: <br /> Applicant - Return all copies to: San Joaquin ounty Public Health Services <br /> f Environmental Health Permit/Services <br /> %( (` 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REM <br /> ITTED CK 0 RECEIV (�? <br /> /ED V DATE PERMIT'NO. �. J``7pG <br /> . 77 <br /> EH 13.24 1� � <br /> .r i A sl�- v , f/ �4./ (�/_ / ,,,��. �7 <br /> t EH 14.25 — �— ­,q-3 b 0 <br />