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0 APPLICATION • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION KA Job 445 N SAN JOAQUIN,PHONE(209)469-3420 P 0 BOX 388,STOCKTON,CA 95201-0388 20-3821-01 .1301 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �Q32-1OI (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described.This application is made in compliance with San 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. APN-44'9 — -02( k,\CJeFro: IIDIt -{iCrii)f-ryfV,(-1✓1 Job Address a r an- d City French CaMpt. Size/Acreage 17 acres Owner's Name Gary Howard Address P • 0 - Box 12346 , Fresno. 9377'ihone , contractor Spectrum/Kleinfelkg�Ss2825 E. Myrtle St License NoS12268 Phone948-1345 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n -Of5TRtJCTJ0t1tB9ator-service-Warr-1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. -PROP.-LfN£ 1 1 borings FOUNDATION AGRICULTURE WELL OTHER WELL -PiTfi WG ,Q' Deep INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6" Dia . ' n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Me of-WelL Casing n Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing_ -specifueshonr Nn ME I"1 Public Il Other n Delta Depth of Grout Seal -T1p"I-G,,oV*nt1C103 ted I I Irnganon _ Approx. Depth I I Eastern Surface Seel Installed by Tf RW Pnrr3tln4.prPri wi Ll Repair Work Done ❑ Type of Pump H.P. __ Stale Work Domtar r.f111 with "hole lug' Well Destruction ❑ Well Diameter Sealing Material i Depth Depth _ Filler Material L Depth ' TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public rower n available within 280 I"11.1 Installation will serve: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Character of wil to a depth of 3 lest: 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 ❑ No. 6 Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Founcanon Property Lina SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: Wall Foundation Property Line J-+ Y ' DISPOSAL PONDS ❑ PAY CC'' E— l I hereby candy that I have prepared this application and that the work will be done in accordance with San Joaquin pn •r6` 1,Fslala laws, and rules and regulations of the San Joaquin County F+4 i if 1f!�4 Home owner or licensed agent's signature unifies the following: "I certify that in the performance of the work for 11&ih this permit is Issued. I shall not employ any parson m such manner as to become subject to workmen's compensation laws of California."Comndor'al lt'ring or tkilp4 Atiacbng signature certifies the following: "I canity that in the performance of the work for which this permit is issued, I shall employ perwav nj sulygci lgorkman a mpa ebnsa tion laws of Califor "•." t - ' ' r t'h;vla[i,LthALlr;rtr I.:.5111 _ ' The applicant m s u for require*Z1 omplete drawing on reverse side- Signed K_�- C' Title: . Senior Engineer Date:11-8-94 /iOR D ARTMENT USE ONLY �u 4[ � ' ADDIIC•Ilnn ActeDlstl bV ° 7 `� " Oste / A • <7, /L� Pit or Grout Inspection by ' Date Final Inspection by _t�j Dswxz/7 Additional Comments: f�� Applicant - Return all copies to: San Joaquin County Public Health Services J Environmental Health Permit/Services G 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-03880 FEE m 1 1 INFO) AMOUNT DUE DUE AMOUNT REMITTED /�CASH CKK RECEIVED BY DATE PERMIT NN :" r].24 1REV ern'i .I o/./2 Y II /I AA O4 / WI ?