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APPLICATION SAN JOAQUIN COUNTY PUBLIC SER S3 flea.A ENVIRONMENTAL HEALTH IVJ IJY 445 N SAN JOAQUIN, PHONE ( 0 � P O BOX 2009, STOCKTON, MLY!W01 PERMIT EXPIRES 1 YEAR FRO //11��UU S.RTT (Complete in Tripl ' c V Application is hereby made Lo San Joaquin County for a permit to conetru t }pA�rnata the work herein descr his application Is made 1n compliance with San Joaquin County Ordinance No. 499a d 1 ie Rules and Regulations of San Joaquin County Public Health Services. 1. Job Address 9249 S. HENRY RD City ESCALON Lot Size/Acreage 96 rp . Owner's Name MIKE DERnTTRSF. Address 546 VANDYKEN WAY RIPON Phone 599-6295 Contractor OWNER Address License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications f� I'I Public CI 1 Other Il Delta Depth of Grout Seal Type of Grout un `) 9bi I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. ____ State Work Done _ 4__ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I* REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public rower is available within 200 feet.l Installation will serve: Residence _.X_ Commercial_ Other Number of living units: I Number of bedrooms _ 4 Character of and to a depth of 3 feet MEDIUM TO COARSE SAND, LT BRN, DMisr table depth 140 ' SEPTIC TANK CK Type/Mfg P&L PRECAST Capacity 1900 GAL No. Compartments 2 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 105 ' Foundation 10 Property Line 170 ' LEACHING LINE IX No. & Length of lines _2 0 60 ' Total length/size 120 ' 4" DIA FILTER BED Distance to nearest: Well 120 '' Foundation 30Property Line 175 ' SEEPAGE PITS IX Depth 2S ' Size 42" DIA MIN Number 4 SUMPS LI Distance to nearest: Well 1R0 ' Foundation 25 ' Property Lin* 240 ' DISPOSAL PONDS ❑ I hereby Certify that 1 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 Homs 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 most cal forr all r*qus in ions. Complete drawing on reverse side. Signed X_ Title: OWNER Date: SEP 24 , 1993 FOR DEPARTMENT USE ONLY Application Accepted by Date Z- Are, Z Pt or out Inspection by ate Final Inspection by Date 3 A ditto I Comments: .t / c Applicant - Return all copies to; San Joaquin County Public Health Services �(�/�� / �L`� + z✓ fR/ Environmental Health Permit/Services W's`q(v+f IV Wf It^� /ft l.Q. ty� . 995 N San Joaquin, P O Box 2009, Stkn, CA 95201 Oa l' ,74 G rlrj/ I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. fx" a IaV.„x sr? I I j 1 3- 9