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f y &VPLIC�'rTnN -- r-7\ r; SAN JOA UIN COUNTY PUBLIC HEALTH SERVIC Lg ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 NOV 1 0 1993 P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH r kERMIT EXPIRES_ 1 YEAR FROM_DAT9 ISSUFP PERMIT/SERVICES (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 Ordinance No. 549 and 1862 and the Rules amd Regulations of San Joaquin County Public Health Services. Job Address 1012 W_ YncPmti t•P AvQ_ CAA Manteca Lot bine/Acreage 11 70O sq Ft Owners Name Ken Hafer Address Manteca phone 2Q9-973-192() 3663 - - 3663 Otnec Circle Contractor BAF Drilling Address (cense No 519428 Phone TYPE OF WELL/PUMP NEW WELL C& WELL REPLACEMENT Cl DESTRUCTION Cl out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well SCI 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 {l Industrial ❑ Open Bottom Q Manteca Die of Weil Excavation All Dia of Well Casing r1 ( I Domestic/Private XXGravel Pack7 C1 Tracy Type of Casing_ PVC Specifications Sch._ 40 t t Public 1-1 Other n Delta Depth of Grout Seal 8' Type of Grout CeMent � 11 InigaUon 2.52Approx Depth I I Eastern Surface Soul Installed by Trimme - Repair Work Done U Type of Pump NA HP State Work bone Well Destruction ❑ Well Diameter tri Sealing Material i Depth C'.Pment to Rentonitg seal - g r Depth 251 Tiller Material a Depth Silica sand filter Rack-14r TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION I I INo septic system permitted it public sower is available within 200 feet I Installation will serve Residence _ al! Other Number of living units Number of bedrooms Character of&ON to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Foundation rty Line LEACHING LINE CI No8 of Imes Total length/size FILTER BED ❑ ante to nearest Well Foundation Property Line SEEPAGE II Depth Size Number SUAAPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ I 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 reputations of 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 perrrtit is issued I shall not employ any person in such manner as to become subject to workmen s Compensation taws of California Contractor's hiring or sub-contracting signature certifies the following "1 Comfy that in the performance of the work for which this permit is issued,I shall employ persons subject to Workman a compensa tion laws of CalNomle"' f ' The applicant must call for all required j4spections Complete drawing on everse side Signed XTitle Date I FOR DEPARTMENT USE ONLY Application Acceptedf ib Date ` Area Pit or Grout Inspection by' Date I Final Inspection by I Oats lAddirional Comments 1 Applicant - Returnl all copies to San Joaquin County public Health Services, I 611 Environmental Health Permit/Services ' 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 1 ' INFO AMOUNT DUE AMOUNT R//''EVIIrTED t-ASH RECEIVED BY DATE PERM17 NO ' "1;1 14 1 rV iin51 r Aa t I9, •Vi i n ]) I 1 1 1I -Z 1 I, I Ili FM�i4 adl I I 1 I 1 �I �I 11 I 1 r� VII 1� I it �I I, �I' 1 1 11 11 j I�I1�1 [ I� 1 IF,