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APPLICATION </ Z SAN JOAQUIN COUNTY PUBLIC HE �VICESOO/3u j ENVIRONMENTAL HEALTH DI� ISIO 445 N SAN JOAQUIN, PHONE (2 9)4 420 P O BOX 2009, STOCKTON, CAS 195( ('20}}}}L PERMIT EXPIRES 1 YEAR FROM DAT�`ISS (Complete in Triplicate ,11, __ �� _ � 'Rlfi's Application is hereby made,to San Joaquin County for a permit to construct altdlvr-inetail-tDe'vo 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. JoD Address 19185 E. Stampede Rd. Cily(LementS Lot Size/Acreage Owner's Name John Teresi Address P O Box 885 Victor Phone ContiaclorPurviance Drilles,lafq,s P. 0. Box 64 , _Li No. 377923 Pnone 887-3554 TYPE OF WELL/PUMPS NEW WELL WELL REPLACEMENT Cl DESTRUCTION Li Out of service well 0 Monitoring Well ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1) 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 X] Open Bottom ❑ Manteca Dia. of Well Excavation 1 8 Dia. of Well Casing 12 3 14 .� RR [id Domestic/Private ❑ Grave Pack 0 Tracy Type of Casing_ Specifications ggaC sand& em, I'1 Public I�l_�OOlh�/er �'�J ,� fl Delta Depth of Grout Seal 2 t(d Type of Grout I Irrigation al�DA.P os:`Gepth I 1 Eastern Surface Saul Installed by Repair Work Done ❑ Type of Pump H.P. _-- State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth — Depth Filler Material i Depth \ TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION DESTRUCTION I aNailableseptic w Ihsystem00 1�[fed it public sower is , UN, 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 �1 SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ( w _ LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number „+ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ^� 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,`( rules and regulations or 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 workmen'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 Is"of California." r The a u call r all a red inspections. Complete drawing on reverse side. Signe �- __ Title: Corporate Secretary Date: 11 /1 /93 _ FOR DEPARTMENT USE ONLY Application Accepted by r7 /) Date Area I; J — Pit or t Inspection by / vC Date /-�°' Final Inspection by n� eUl-lDate Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ` e 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CCK-1RECEIVED BY DATE PERMIT NO INFO\) )� /�! /�.,� /�/� 71 µ/ O SEH 1J 24 IREv.r roar �a . MI oat (.r/�7 '/,�1�/ �i�f` /� � �.7 ru v_M