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_ APPLICATION SAN JOAQUIN COUNTY PUBLIC SERV ICES fVE 445 N SAN ONMENTAL JOAQ IN, PHONE ( 8-334420P O BOX 2009, STOCXTO ,"rCQ�� }9�5ll11PERMIT EXPIRES 1 YEAR FR rD?ITE(Complete in Trip i9Application Ss hereby madeto San Joaquin County for a permit to conatr a vor This 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 9948 Harlan Rd c„yFrench Camp Lot Size/Acreage93 Arrpc Caterina Fredrick 94123 _ Owner's Name Address 1976 Lombard San Franri crn Phone ucketts Pum & Well . P. 0. Box 602 Linden 95236 Contractor F p Address License No.521666 Phone 944-5969 TYPE 4 — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ,?I Public ❑ Other fl Delta Depth of Grout Seal Type of Grout I I Imgation __.Approx. De th.111 Eastern Surface Seal Installed by — Repair Work Done )9. Type of Pump H.P. State Work Dona :U eisb Well Destruction Cl Well Diameter r/ Sealing Material L Depth Depth Piller Material L Depth TYPE OF SEPTIC WORK; NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public wwar is available within 200 fast.) Installation will serve: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED ❑ lance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify 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 subcontracting 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 California." The applicant call for all r it ins p s. Complete drawing on reverse side. Signed A Title: Contractor Date: 1-15-94 FOR DEPARTMENT USE ONLY Application Accepted by Date A Pit or Grout Inspection by Date Final Inspection Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 r3P FEEO AMOUNT DUE CASH AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. �J`. INF / O/ PER . EN EH;3.24 1x IaEV.irxsi c)-0I \