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APPLICATION FOR PERMIT 11 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 PERMIT EBPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applleation Is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein deaeribed. This application is mde in comillance with Ran Joaquin County Ordinance Me. 549 and 1862 and the Rules amd Regulstlene of Ban Joaquin County Public Health Services. 5400 Pacific Avenue cityackr nn Lot Site/Acreage Jab Address 5400 Wegt Ovmeis Naim Montgomery Ward __ Address 411701 Fr-m lir 11rd Phone - 7771 [C' C57•S100// (916)fa 1X25 Contractor - -"-- .liddr:.. %`//�Z GA License No._; phone TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well ❑ �y PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ Monitoring Yell7C DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESO-150 ft DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wen Excavatio _ 2 Did. of We" Culrp U' rl Domestic/Private ❑ Gravel Pack ��9❑ Tracy Type of Cuing_ Speciricarfons 1'I Ptrblk �fX�OGter Boring AL-rl Delta Depth of Grout Seal /,, • T//YW.of Grout 111,6940on 5_3apMoa. Depth I I Eastern Surface Seal Installed by Rsoak Work Dom L1 Typo of Pump H.P. Stara It and no Wall Destruction ❑ Wen Diameter Sealing Material A Depth I. eat 1.ement J1urC t-bottom) Depth Flller Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INR septic system permitted If public sewer is available within 200 lest.l Installation will serve: 1lesidence_ Comrerclal_ Other Number of living units: _ Number of bedrooms Character of sos to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartrmnto PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Wan Foundation Properly Lime LEACHING LINE ❑ No. A Length of situ Total length/sirs FILTER BED ❑ Distance to manse: Won Foundation Property Ll w_, .E_' 1 SEEPAGE PITS 11 Depth Sire Number ULU U l SUMPS LI Oisln to nearest: Wall— Foundation Property,L'eIIMUI'" DISPOSAL PONDS O i" 11' 1' I hereby certify that I have prepared this application and that the work will be done m accordance wit N�SYH JdkilUki bbuhty ordinances, state taws, and rules and rogutallons of the San Joaquin County Hone owner at Roamed agent's signature canilles the following: "I certify that In the performance of the work for which this permit Is issued, 1 shall mot empty any person in such manner as to become subject to workmen's compensation laws of California." Contractors hiring or out,contracting signature comiFtas the following:"I eattify,that in the performance of the work for which this permit Is Issued,I shelf employ persona subject to workmen's compensa- tion laws of CelNorr a.• 1 The applicant usrull for M igylked fnspaptlons. Complete drawing on reverse side. See Attached Figure Sip ffL 4�'lll( Title: Geologist Date: 11/30/92 FOR DEPARTMENT USE ONLY Application Accepted by �� Date • Area r Ph or Grout Inspection by Oete� Fine1 Inspeetlon by Dau /LGClJ t Addhlonal Comments: $ — i ' Applicant - Return all copies to: San Joaquin County Public health Services �U` Environmental Health Permit/Services /�J 445 R Sae Joaquin, P O Box 2009, Stkn, OA 95201 ` 51 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PfRMIT NO. INfO CASH tX fX gto"1♦ c 9 " /�� 9�i i •"OLS