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APPLICATION it _ SAN JOAQUIN COUNTY PUBLIC SER ENVIRONMENTAL HEALTH IV IQQ�� `IN�d 445 N SAN JOAQUIN, PHONE ( 09E- 0 P O BOX 2009, STOCKTON, QAIow01 �_ PERMIT EXPIRES 1 YEAR FRO /1�U SSU r (Complete in Tripl C f�� V_�=3 Application is hereby made to San Joaquin County for a permit to tonstru t PPppgy��Rgr neta7l the work herein descr�it-i de his application 1e made in contpllance vith San Joaquin County Ordinance No. 49�add 11th a Rules and Regulations of San Joaquin County Public Health Services. 1. Job Address 9249 S. HENRY RD Cir, ESCALON Lot Size/Acreage 6. Owner's Name MIKE DEROUSSE Address 546 VANDYKEN WAY RIPON Phone 599-6295 Contractor OWNER Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ 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 _ 6. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CIDomestic/Private L1 Gravel Pack L1 Tracy Type of Casing_ Specifications - r� LI'I Public 1.1 Other (l Dena Depth of Grout Seal Type ofGrout_ �`1 I I Irrigation _Approx. Depth 1 1 Eastern Surface Seal Installed by 9lN Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth (� `• Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION IX REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 leet.l 60Installation will serve: Residence -X- Commercial_ Other Number of living units: 1 Number of bedrooms 4 Character of wil to a depth of 3 feet: MEDIUM TO COARSE SAND LT BRN DFVYter table depth 140 ' LSEPTIC TANK IX Type/Mfg &T. PRECAST Capacity 1900 GAL No. Compartments 2 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well 105 ' Foundation 10 ' Property Line 170 ' Lr LEACHING LINE IX No. 8 Length of lines 2 @ 60 , Total length/size 120 ' 4" DIA FILTER BED - Distance to nearest: Well.__120' Foundation 30 r Property Line 175 r LSEEPAGE PITS IX Depth 25 t Size 42" DIA MIN Number 4 SUMPS LI Distance to nearest: Well 1R0 r Foundation 25 ' Property Line 240 ' DISPOSAL PONDS ❑ L1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shell employ persona subject to workman's compensa tion laws of California." The applicant must cal for all req/uir to ions. Complete drawing on reverse side. Signedx � !`l a, - Title: OWNER Date: SEP 24 , 1993 FOR DEPARTMENT USE ONLY //Application Accepted Dy Dare Z Area �- /' Pi,or out Inspection by Date t+ Final Inspection by Date 3 A di[io el Commanu: F / -Cp- �' rC �- Ile /! Applicant - Return all copies to: San Joaquin County Public Health Services � (�/19&`;1 J11a/ a,. Environmental Health Permit/ServicesArlt 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 4 0'' { //( (fu— f. FEE AMOUNT DUE AMOUNT ftEMlTTEO CK DATE PERMI7'NO. ,IIfNFO /✓ )1CASH RECEIVED BY 1 �r Lil, 1a 24 IAEV.-11.31�t1 1 / Y' 1 Y� 1"r: t ir (- � .. .. C1 /7r �� f)Z nfV w fLM 1 V