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ij APPLICATION FOR PERMIT ; i SAN J'OAQUIN COUNTY PUBLIC HTALTH ,�.ztVICES �i ENVIRONIIENNTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 IE P O BOX 2009, STOCKTON, CA 95201 II. PMWXT__ER1R93 x Y R D !) (Complete in Triplicate) Apylicstion is hereby, made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in conviiance with San Joaquin County Ordinance Ro. 549 and 1862 and the Rules and Regulations of San Josquln.County Public Health Services. Job Address 1 Ch _ /Soo v__J RA C Y Lot size/Acreage Owner'sName SASSO I AUD DEV Address TRACY Phone 835-9000 Contractor ENNINGS BROS . Address 3525 PELANDALE AVE. 290813 545-918 License No. Phone d TYPE OF WELL/PUMP: II NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Ci PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER )(3)( Monitoring well O v J DISTANCE TO NEAREST: SEPTIC TANK N O CSF SEWER LINES AL0 PLE-- __ DISPOSAL FLD. PROP. UNE FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS T J INTENDED USE TYPE�OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E1 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Din. of Well Casing El Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public CI Other fl Delta Depth of Grout Seal Type of Grout 1 I I Irrigation —.Approx. Depth i I Eastern Surface Sea] installed by Repair Work Done 0 ' Type of Pump H.P, State Work Done Wall-DestructionWelt Diameter sealing Katerial i Depth T E S.T. H O.L E Depth :` Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted i1 public sewer is l available within 200 feet.) Installation will serve: Residence Commercial_ Other -� Numbs of Wing Unita: Number Character of Boit to a depth of 3 feet: a Water table depth SEPTIC TANK. 0 Type/Mfg i �- No. Compartments PKO. TREATMENT PLT.O 11 PermIt M f ♦ Method of Disposal Distance to nearest vvbrk NW14mkm i Ola Property Line f LEACHING LINE ❑ No. i length of lir Vir j '"t I t8 Total length/size FILTER BED CI Distance to nearest. Well Foundation Property Line I �r SEEPAGE PITS t I OepthF Site Number SUMPS LI Distance to dearest: well Foundation Property Line f DISPOSAL PONDS 0 17 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 taws of California."Contractor's hiring or sub-contracting signature *' "nifias the following: "I certify 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 Califomis." The applicant must call for MI requirgd inspections. Complete drawing on reverse si S'gnditle. ` Date. OCT. 2,? . 1992 'F FOR DEPA TMENT USE ONLY h Application Accepted by �� r - Date Ate^a/� Z Z Arae Pit of Grout Inspection by I Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services i� 446 N San Joaquin-,.. P O Born 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. INFO CASH i] { t