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APPLICATION I i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES F ENVIRONMENTAL HEALTH DIVISION j� 445 N SAN JOAQUIN, PHONE (209)468-3420 v V P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES L YEAR FROM DATE ISSUED „ (Complete in Triplicate)„ {{ Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This 1E application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f Job Address 5 3920 33a6chiai " City Lindell Lot'Size/Acreage —23 r _ Owner's Name Dave PodeS a Address 12344 E. Fairchild Phone I Purvian'ce Drillers, In P. o. Box 64,Linden, Ca i Contractor , ress License No. 377423 ___Phone a 8 7_ TYPE OF WELL/PUMP: f NEW WELL.� WELL REPLACEMENT 171 DESTRUCTION 0 Out of Service Well ❑ t PUMP•INSTALLATION'% SYSTEM REPAIR ❑ OTHER p Monitoring,Well D15TANCEil NEA REST:;SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS oe :1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 fi Dia. of`Well Casing ' {a Domestic)Private ❑ Gravel Pack E-1 Tracy Type of Casing_ Specifications R ` i'1 Public,. X i-1 Other (71 Delta Depth of Grout Seal _ 230 Type of Grout cement irrigation €. , 450 Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work'Done U Type of Pump _46 - - H,P. 310 State Work Done.Q2 c> - Well Destruction ❑ Well Diameter Sealing Material & DepthV_LILs k � t..c rp i Depth Filler Material & Depth i TYPE OF SEPTIC WORK: -NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 1No septic system permitted if public sewer is available within'200 feet.) 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. _ O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.'D... Method of Disposal' Distance to neares: Welt Foundation Property Line LEACHING 6NE ❑ No. & Length of IiA.es Total length/size FILTER BED n Distance to nearest: Well _ Foundation Property Line SEEPAGE PITS 11 Depth Size Number I SUMPS CI Distance to nearest: Well :Foundation Property tine DISPOSAL PONDS ❑ 1 I hereby cenify that I have prepared this application and that the work will be done-in accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin County , f Home owner-Mr licensed agent's signature cenifies the following: "I certify!that.in.the-performance-of'Lthe.work for which.tKis�permit is issued, I shall not " p employ any person in such manner as to become subject 10 workman's compensation laws of California." Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of the work fgf.'thick this permit is issued, I shall employ persons subject to workman's compensa- ' tion la o ornla." The plicam t call for aquijdinspe�ctions. Complete drawing on reverse side. Signed Title: Corp.. Secretary Date: 7/01 /92 FOR DEPARTMENT USE ONLY I 1, Application Accepted by Date 7 `� y Area Pit or rot Inspection by / 1 Date <1 Final Inspection;by Date d �- Additional Comments: r Applicant - Return all copies to: San Joaquin County Public Health Services !/YJG�T� i1r1??1 a� '�' L l (,r13� Enviroamental'Health Permit/services �W 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK 11 �hstrl FO I AMOUNT DUE AMOUPz� NT REMITTED CASH RECEIVED BY DATE PERMIT C). . EH 13-211Nt:V.r/N5i D 7 p 7 r �'� '�� ] EH 1�•2a 40 00