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F - JOAQUIN COUNTY PUBLIC REAI " SER- ICE <br /> RfV I RONMENTAL HEALTH D I I IONI I�a�� i <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 � °� <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> G - PERMIT VfnTn-0 ' "� 1'I FROM DATE ISSUEDU (Complete in Triplicate) CNVIRONMENTALyEALTH <br /> ))cation is here made.to San J DERMIT/SERV!C`S <br /> Application by oaqul County for a permit to construct and/or install the work herein descr?bed. This <br /> application is made in compliance with San Joaquin County Ordinance No. 5L9 and 1862 and the Rules and Regulations of San <br /> Joaquin County ?ublic neutn Services. <br /> Job Address 920 N. Shaw Road city Stockton Lot Size/Acreage 2.5 AC <br /> Owner's Name Fresh Start Foods T-C. Aoaress 920 N. Shaw Road Stockton <br /> Phon 209-462-3610 I <br /> Contractor Taber Consultants Ao-_,eSs 536 Galveston Street License No. 466270 Phone 916-371-1690 <br /> TYPE OF WELL/PUMP: NEW WELL C `NELL REPLACEMENT ;: DESTRUCTION L, Out of Service cell Z <br /> PUMP INSTALLATICN ( SYSTEM REPAIR �7 OTHER X Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES soil borings <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 7 Industrial If Open Bottom _ Manteca Dia. of Well Excavation inch Dia. of Aj.11 Vias no _ <br /> FI Domestic/Private _ Gravel Pack Tracy Type of Casing_ Specifications <br /> FI Public (1 Other Delta Depth of Grout Seal Type of Grout cement -Qu=x2 <br /> i i Irrigation _Approx. Deptn eastern Surface Seal Instilled by <br /> Repair Work Done _ Type of Pump H.P. State Work Done _ <br /> Well Destruction u Well Diameter Sealing Material i Depth <br /> Depth ?iller Material i Depth <br /> TYPE OF EPTIC WORK: NEW INSTALLATION i REPAIRlAOOITION DESTRUCTION I I INo septic system permuted d public sower is <br /> available within 200 feet.) <br /> Installation wu e: Res+dence Comrnerctal Cuter <br /> Number of k%nng units: Number of bedrooms <br /> Character of soil to a depth o feet: r`table depth <br /> SEPTIC TANK ❑ Type/M Capacity No. Comoartments <br /> PKG. TREATMENT PLT. C Method of Disposal <br /> Distance to nearest: Veli roundation Prooertv Line <br /> LEACHING LINE ❑ No, b length of Total length/size <br /> FILTER BED C:stance nearer Wes Fo soon Property Line <br /> SEEPAGE PITS I Depth Size <br /> SUMPS LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL ONDS ❑ <br /> I hereby certify that I have prepared this appitcauon ana that the work will be done in accorcance with San eosin county ordinances, state laws, and <br /> rules and regulaisons of the San Joaquin Count? <br /> Home owner or licensed agent's signature certifies the following: ''I certify that in the performance of the work for which this Pernut is issued. I shall not <br /> employ any person in such manner as to beton»subject to , ..Jmpensauon laws of California." Contractor's hiring or sut>contractirtg signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons suotect to workman's compensa- <br /> tion laws of California." <br /> The applicant must call or an r ed inspections o ate at wing on reverse side. <br /> Signed Title: Senior Geologist Date. 7/26/94 <br /> QEPAFtTMENT USE ONLY / �J <br /> Application Accepted by t Gw ate Area <br /> Pit or Grout In r ' r 2I 0 <br /> apection by .ate Final Inspection by ate <br /> f <br /> Addrilonal Comments: <br /> .applicant - Return all copies to: San Joaquin County Public Health Services S_ Q <br /> °avir^^^ tai Health Permit/Services <br /> 45 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> ,NFO FEE AMOUNT DUE AMOUNT REMir'ED "a5H RECEIVED BY DATE 7 PERMIT NO. <br /> Pa ae 1 <br /> jQ) f� //J 0 3:- <br /> EH 4.25 <br />