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APPLICATION SAN JO QUIN COUNTY PUBLIC SSR Inn.A ENVIRONMENTAL HEALTH IV QQ1 445 N SAN JOAQUIN, PHONE ( 0 141 0 V P O BOX 2009 , STOCKTON, 01lIt r w 01 � PERMIT EXPIRES 1 YEAR FRO U it SbUED n �� ` (Complete in Tripl c L/ i (S c13 Application in hereby made.to San Joaquin County for a permit to constru t fy,��1��r nota the work herein desdr�b"eZ7 his application Ie made in compliance with San Joaquin County Ordinance No. 49 edd'1 a Rules and Regulations of San Joaquin County Public Health Services. - bill' 9249 S . HENRY RD Job Address City ESCALON Lot Size/Acreage owner's Name MIKE DEROUSSR Address 546 VANDYKEN WAY RIPON Phone 599-6295 Contractor OWNER Address License No. Phone } TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ 6. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS _ V, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout- I `I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by T `� Repair Work Done ❑ Type of Pump H.P. -__ State Work Done_ I Well Destruction ❑ Well Diameter Sealing Material i Depth '►. Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION IX REPAIR/ADDITION 1 1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence _X_ Commercial_ Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: MEDIUM TO COARSE SAND, LT BRN, D�ryter table depth 140 r i SEPTIC TANK M Type/Mfg P&L PRECAST Capacity 1900 GAL No. Compartments 2 ■a PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 105 ' Foundation 10 ' Properly Line 170 ' `LEACHING LINE X No. i Length of lines _2 @ 60 ' Total length/size 1201 4" DIA FILTER BED Distance to nearest: Well 120 ' Foundation 301 Property Line 175 ' SEEPAGE PITS IX Depth 25 ' Size 4211 DTA MITI Number 4 V SUMPS LI Distance to nearest: Well 180 ' Foundation 25 ' Property Line 240 ' DISPOSAL PONDS ❑ t 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 regulations 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 permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the following: "I cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must cal for all requir In ions. Complete drawing on reverse side. Signed % (tin L/. Title: OWNER Date: SEP 24 , 1993 r FOR DEPARTMENT USE ONLY Application Accepted by 'I /� Date Z- Area z- P for out Inspection by . Date t/ `t 160 Final Inspection byAM Date e3 ,� •� c A ditio el Comments: 6 - fir Applicant - Return all copies to: San Joaquin County Public Health Services )d 1"/ Environmental Health Permit/Services : It.f 445 N San Joaquin, P O Box 2009, Slit , CA 95201 -LZ Il INFEO ,/pAMO(LUNNT DOE AMOUNT!REMITTED CASH RECEIVED By DATE o ('�PERMIT'NO. "13-241REV..1"51 5 1 / T 1 0 c I ---�l�cL� -1 �-1 9 - EM 14 20