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APPLICATION 3 <br /> — v <br /> SAN JOAQUIN COUNTY PUBLIC HE T��$ VICESC7()i3v 3 <br /> ENVIRONMENTAL HEALTH DI I <br /> 445PN0SAN <br /> OXJ 009, STOCKTON, AOAQUIN, PHONE (2P/4��('99�10 <br /> PERMIT EXPIRES 1 YEAR FROM DATE�`iSS <br /> (Complete in Triplicate) /Q <br /> Application Is hereby made,to Baa Joaquin County for a permit to construct and•Jar-inatal3�thcvo�7--ZIs <br /> application is made in compliance with San Joaquin County Ordinance No. 549 <br /> Joaquin County Public Health Services. and 1962 and the Rules and Regulations of San <br /> Job Address) 91 85 E. Stampede Rd CayClementS Lot. Size/Acreage <br /> Owners Name John Teresi Address P. 0, Box 885 Victor Phone <br /> Conlraclo(Puryiance Drilles,Ingm P. O. Box 64, LindflAensehlo. 377923 Phone 887-3554 <br /> TYPE OF WELL/PUMP: NEW WELL Ot WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 'l7 Opan Bottom ❑ Manteca Dia. of Well Excavation 1 R Dia. of Well Casing <br /> 6d <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ StePl Specifications-1 RR <br /> I'I Public f-I 0 n Delta Depth of Grout Seal d Type of Grout9c;Ar S, anal emE <br /> I I Irrigation p ox. epth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth Filler Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION 11 (No septic system permitted if public sewer is \ <br /> available within 200 lest.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lim <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 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�+ <br /> rules and regulations of the San Joaquin County <br /> 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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I comfy that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workmen's compensa- <br /> tion laws of Cslifornle." , <br /> The acall r NI Bred inspections. Complete drawing on reverse side. <br /> Signs t�r Title: Corporate Secretary Da1B: 11 /1 /93 <br /> „o FOR DEPARTMENT USE ONLY ! } <br /> Application Accepted by Date 1 Area ; <br /> Pit orr�t Inspection by O ate -w Final Inspection by S < Date -1 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stk., CA 95201 <br /> INFO AMOUNT <br /> /DUE AMOUNT REMIT-TEDCC/K RECEIVED BY DATE 2 PERMITNO. <br /> EEM <br /> H;4.263_24(REV.rixnl0 �0 ,'�V ✓U -/� �-"S� /� -1 �3 a <br />