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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESO I �1 <br /> ' ENVIRONMENTAL HEALTH DIVISION KA Job <br /> 445 N SAN JOAQUIN,PHONE(209)469-3420 <br /> P O BOX 388, STOCKTON, CA 95201.0388 20-3821-01 .G01 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' f932 �f�f8 (Complete in Triplicate) <br /> Application is hereby made w San Joaquin County fora permit m construct and/or install the work herein described.This application is made in compliance with San <br /> ' Joaquin County Development Title Section 9.1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. <br /> APS #193--2116 02 Change W I IGD t +I-") <br /> Job Address ` Y d oty French Cam[pt Size/Acreage 17 acres <br /> ' Owner's Name Gary Hcward Address P .O . BOX 12346 ,Fresno , 9377ihone <br /> Contractor Spectrum/Kleinfelj'ygg552825 E . Myrtle St License No512.268 phw1C948-1345 <br /> ' TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACEMENT (l Ma#1'$1 <br /> PUMP INSTALLATION G SYSTEM REPAIR 0 OTHER Monitortna Mall ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F1.13. —PBela.-uw I I borings <br /> ' FOUNDATION __ AGRICULTURE WELL OTHER WELLZQ' Deep <br /> INTENDED USE TYPE OF WELL FROBLEM AREA CONSTRUCTION SPECIFICATIONS 6" Dia . <br /> ❑ Industrial ❑ Open Bonam ❑ Manteca Dia. of Well Excavation. -Dia_daMelLCaaiog <br /> ' fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-_ -5peciReAtiatr�t^ rad <br /> Il Public I I Other (l Delta Depth of Grout Se21 -TYpa­&t- mrftA tel Cleated <br /> I I Irriumion _ Approx. Depth I I Eastern Surface Seal Insiailed by Tf rW pnrnnnt.prAA wLi- 1 <br /> ' Repair Work Dona U Type of Pump H.P. -_ State Work Oonaba_C3r 311 T•T' th "hole lt: <br /> Wall Destruction ❑ WON Diameter Sealing Material i Depth <br /> Depth _ Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I 1 INo septic system permitted it ppblic sewer e <br /> ' available within 200 fei <br /> Installation will nerve: Residence_ Commercial_ Other <br /> Number of living unit: __ Number of bedrooms <br /> Chaucter of sol to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compemnenta <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest Well Foundation _ Property Line <br /> ' LEACHING LINE ❑ No. b Length of lines — Total length/alae <br /> FILTER BED ❑ Distance to merest: Well Founo t.on Properly Lina <br /> ' SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Progeny Line fE e.!'," <br /> DISPOSAL PONDS ❑ PAYMENT <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin sun lows, and <br /> rules and regulations of the San Joaquin County i}+.11 h {DIf� <br /> Home owner or licensed agent's algrature certifies who following: "I candy that in the performance of the work for A11,hF!hes pehm(ik i 9, 1 shall nor ,6 <br /> employ any parson m such manner es to become wbNct to workman's compensation lee.of California.'" Contraclor'at 1rev W;�tlbrlxdAffli e�y signature — <br /> ' cartibes the following: "I certify that in the performance of the work for which this permit is issued, I shall employ gatWlt'.ig yq Y+Opmtall'R.lbtrlpenes- <br /> tion laws of Calif <br /> h y;Ylld <br /> The apdicanr s oa for • require ins ompleu drawing on rave/es side. - <br /> ' Signed �" Title: Senior Engineer Data:11-8-94 <br /> y/5/pR D ARTMENT USE ONLY F <br /> Application Accepted by oats A a 0'L �I <br /> ' Pit or Grout Impaction by �� // Date Final Inspection by Dote,_4_ 4T ,( <br /> Add "'y'itional Comments: �� � <br /> d �/� 6 - <br /> Arplicant - Return all copies to: San Joaquin County Public Health Services - <br /> Environmental Health PennitlServices _ 1 <br /> (��'1J, 445 N.San Joaquin,P.O.Box 388.Stockton,CA 95201-0388 �•�2�,r1,1 4.FEE _ <br /> 1 INSF(JO[t AMOUNT DUE AMOUNT REMITTED / RECEIVED BY OI•AJTE/,(/V U PEAMOI/TND. <br /> �H 13.24 �• �� 1 �l .7 I �,( 4` cel <br /> n U43(REV. irnpl <br /> a <br />