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SII APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH ENSERVICES ENVIRONMENTAL HEALTH DIVISION SPA"ENT Rec 445 N SAN JOAQUIN, -PHONE (209)468-3420 iJ) P O BOX 2009, STOCKTON, CA 95201 Ja,,, NOV Z�3,1993 W1 JOA[U)AI COU PERMIT MIRES 1 YEAR FROG' DATE ISC HEALTN7Y H SERVICES (Complete in Triplicate) � IkOrwkNr - I� AL HEALTH Ofv15bN Application is hereby made to San Joaquin County for a permit toconstructand/or install ;the work herein described. This application is made in compliance with San Joaquin County Ordinsace No. 51+4 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 503 WEST LARCH ROAD JobAddresa City TRACY Lot;�Size/Acreage_�„5 ACRES,,,,,,, 343 SANSOME STREET, SUITE 900 owner's Name HELLER FIRST CAPITAL CORPAddress SAN_FRANCISCO f'A- 94104 _ Phorte '14141 97a 4F7f1f PO BOX 2664 Contractor OWERCORE' S_01E"_SRMPL_EN&ttF C. NTIOC ,,_SA 94531 _ License No 66211 F, �' Phone �4if1177R_FiRi F" TYPE OF WELL/PUMP- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Yell ❑ PUMP INSTALLATION ❑ N SYSTEM REPAIR ❑ OTHER ❑ ,!; Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '^^ 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia: of;''Well Casing I 171 DomesticlPrivate ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications ['1 Public 1:1 Other --n Delta - Depth of Grout Said 'i• Type of Grout I I Irrigation —Approx. Depth l I Eastern , Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done_ Welt Destruction ❑ Well Diameter .Sealing Material i Depth Depth Filler Material i Depth w` TYPE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAtR1ADOITION 1 1 DESTRUCTION 'l I lNo Septic system i' p "thin permitted if public sewer is available within 200 feet.).» Installation will serve: Residence __. Commercial_ Other ` Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK. ❑ T f ypalflAtl� .Capacity Na. Compartments . PKG. TREATMENT PLT. ❑ „' '° Method of Disposal Distance to nearest: Well Foundation Property Line fi LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line" ,, SEEPAGE PITS 11 Depth Sue Number 'h i, SUMPS LI Distance to nearest: Wail Foundation -Property Line+' DISPOSAL.PONDS ❑ I hereby certify that I have prepared this application and that'the work will be done in-accdrdanca with San Joaquin countyordinances, state laws, and u rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following; "t 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 or sub-contracting signature r, certifies the following: "I canify that in the performance of the work for which this permit is issued. I shall employ persons sub-ict to workman's compensa- tion laws of California." ` Tha applicant mus all for ail requirIns ctions. Complete drawing on reverse side. Signed �, tJi' -�=, � - Title: �o 1� iS r Date:aid 11 -17-93 FOR DEPARTMENT USE ONLY d��• a, ''ilii: Application Accepted by Date /! 3d Area 1 Pit or Grout Inspection by Cat eY Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services " ' r Environmental Health Permit/Services 445 N San Joaquin, R 0 Box 2009, Stkn-, CA 9520i` •f . il�l� FEE AMOUNT DUE AMOUNT REMITTED 5 Ip INFO �j it RECEIVED 9y 6ATEp -' PEAMIT'NO. 7 EM u•2u InEv.iihsr s "- Q g �g Ili (•3 VO J PCIgQ L EM t1.2a