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lla • APPLICATION r �r- SAN JOAQUIN COUNTY PUBLIC HE T�p(ymc ENVIRONMENTAL HEALTH DI I9��0Q� 445NSAN J ISTOHTON NC (ZOC 5 cov POOB009Fwdo# I I ^�( PERMIT EXPIRES 1 YEAR FROM D TE UED O Llo V (Complete in Triplica e) Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein describdd. This application in made in compliance with San Joaquin County Ordinance No. 549 nd 1862 and the Rules and Regulations of San Joaquin County Public Health Services. (v.E/r ..�? Job Address DeBROGGI RD. 6�Aa41 -5i City L_ODI Lot Size/Acreage owner's Name FLAG CITY L . P . Address 1820 W KETTLEMAN LN I ODTPhone .1,14-6613 Contractor HENNTNGS RROS_ DRTI I Address 3SM_pELANDDAj F Mj onEST(1 License No.�O(1R1�Phone 545-1125 TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well LT DISTANCE TO NEAREST: SEPTIC TANK NONE SEWER LINES 501 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS S �r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /'� /� 0 ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing rr O Domestic/Private EX Gravel Pack ❑ Tracy Type of Casing__STE EL / Specifications 1�oga ig KI Public 1-1Otherfl Delta Depth of Grout Seal Type of Grout 3011 G I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by DRILLER MMHETftli_=� Repair Work Done ❑ Type of Pump H.P. .__ State Work Done _ '00 C`�,d. ` \) Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION-I I INo septic system permitted if public rawer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other y, Number of living units: _ Number of bedrooms Character of and to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, ompartments PKG. TREATMENT PLT. ❑ Me at�dy y Distance to nearest: Well Foundation Property'r� �vs * Mas. . LEACHING LINE LI No. b Length of lines Total ten� q_ 4 CoQ m FILTER BED CI Distance to nearest: Well FoundationJc� +l'u,+AI •vv ----FIVV��QNM�r�e,�A4TFi +r SEEPAGE PITS 11 Depth Si:e Number --arm SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or 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 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 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of Celifornla." The applicant must call for all required inspections. Complete drew n on r ver a side. Signed x ` nw-,,. � �)1.-b�1 . �-'�/ � �rHe`r�-`-� Date: MAY 23, 1994 FOR DEPARTMENT USE ONLY ` Yr Application Accepted by Date ✓ Area 7- �Y Pit or Grout Inspection by Final Inspection by Date Aq Additional Comments: _9k 4 — Applicant - Return all copies to Sa o County Public Health Services 1 „ 1 tai Health Permit/Services C"dc OM KOS4 Joaquin, P O Box 2009, Stkn, CA 95201 / W f - 67 r fe— NFO AMOUNT DUE A U T EMITTED CK H RECEIVED BY DATE PERMIT'NO. • EM 11-2x IPEV.liner (�.- / , � �� r/,{yy� nn 1' � '�3-{� 40 �J EM 3 24 / lV U /// 77L" "`��PPP CLC