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APPLICATION SAN JOAQUIN COUNTY PUBLIC iE SERVICES ENVIRONMENTAL HEALTH D rn 445 N SAN JOAQUIN, PHONE ( 8-3420 J P 0 BOX 2009, STOCKTO , PERMIT EXPIRES 1 YEAR FR F9A# (Complete in Trip i9W,# Application is hereby made to San Joaquin County for a permit to constr a vow ereln described. This application is made in convliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 9945 Harlan Rd cavFrench Camo Lot Size/Acreage23 ACYPq Caterina Fredrick 94123 _ Owner's Name Address 1976 Lombard San Francisco Phone (G1 S -0572 pucketts Pump & Well P. 0. Box 602 Linden 95236 Contractor Address License No.521666 Phone944-5969 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dis. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �I Public 1 I Other Ll Delta Depth of Grout Seal Type of Grout ii Irrigation _Approx. OB th I I Eastern Surface Seal Installed by Repair Work Done 39. Type of Pump H.P. State Work Done t? Well Destruction ❑ Well Diameter r/ Sealing Material i Depth Depth _45-0-1 S0/ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE U1 No. i Length of lines Total length/size q7\S FILTER BED ❑ lance to nearest: Well Foundation Property Lina 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 Sen 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 persona subject to workman's compensa- tion laws of California." The applicantcall for Contractor all r it insp s. Complete drawing on reverse side. Signed X Title: Date: 1-15-94 FOR DEPARTMENT USE ONLY Application Accepted by _ - y Date Ar Pit or Grout Inspection by Date Final Inspection bye 2 ��JDate�iY / 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 FEE AMOUNT DUE AMOUNT REMITTED DASR RECEIVED By DATE / PERMITNO Ly3(D INFO . SEH 13-I4IeEV.rrner EH ta-ze I `L¢J d _ Ill v'v