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T 9 APPLICATION SAN JOAQUIN COUNTY PUBLIC �}SERVICES ENVIRONMENTAL HEALTHDMAOIT rn_ ' 445 N SAN JOAQUIN, PHONE ( � 38-3420 , V P O BOX 2009, STOCKTO ' RERMIT EXPIRES 1 YEAR FR F#g (Complete in Trip i1W# Application is hereby made,to San Joaquin County for a permit to constr a vor ere n described. This application ie made in compliance vlth Sao Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ' Joaquin County Public Health Services. Job Address 9948 Harlan Rd CityFrench Cama Lot Size/Acreage23 ArrPS Caterina Fredrick 94123 Owner's Name Address 1976 Lombard San Franricrn Phone X5115 -057295236 Contractor Picketts Pump & We1lAcc Access P. 0. Box 602 Linden License No.521666 Phone —5969 ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDIA11ON�- A19RICULTUREWELL' - OTHER WELL PITS/SUMPS'_ " - - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' (I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications q_1 Public 1:1 Other Ll Delta Depth of Grout Seal Type of Grout 41 Irrigation —.Approx. De th I I Eastern Surface Seal Installed by Repair Work Done )6, Type of Pump H.P. ha —.__ State Work Oona ' Well Destruction ❑ Well Diameter rr Sealing Material i Depth Depth /-S�f Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) ' Installation will serve: Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Character of soll to a depth of 3 feet: 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. 8 Length of lines Total length/size FILTER BED ❑ tante to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size Number SUMPS _ LI Distance to nearest: Well _ _ Foundation - _ Property Line__ DISPOSAL PONDS ❑ 1 hereby comity 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." Contractors hiring or sub-contracting signature certifies the following: "I certify that in the pemormence of the work for which thin permit is issued, I shell employ parsons subject to workman's compensa- tion laws of California." The applicant call for all r it ins p t a. Complete drawing on reverse side. Signed x Title: Contractor Date: 1-15-94 FOR DEPARTMENT USE ONLY Z-41({- Application Accepted by Date Ar / Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ,y 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 �•h/1/1/i 'JD/� FEE I AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO, INFO h �s a q� R 1Cm11REV. /mei moi V H 117a