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APPL I CTAT I uN <br /> SA, JAQUIN COUNTY PUBLIC HEAT-TI ERT ICESIR <br /> j�?, <br /> ENVIRONMENTAL HEALTH DIVISION �� nj����i ,� h) <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 �� I t'3 <br /> 0% 2009, STOCKTON, CA 95201 <br /> . � JUi_ 2 <br /> TER-M77 <br /> "T770 I 77A1R FROM DATE ISSUED <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> Application is here made.to Sea J PERMIT/SERVICES <br /> pp by Joaquin County for a Permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin Ccunty Public ae—La Services. <br /> Job Address 920 N. Shaw Road City Stockton Lot Size/Acreage 2,5 AC <br /> Owner's Name Fresh Start Foods Tac, address 920 N. Shaw Road Stockton Pon 209-462-3610 <br /> w,¢e,�- 5aC. C y prig <br /> Contractor Taber Consultants ;.gess 536 Galveston Street License No. 466270 Phone 916-371-1690 <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ( DESTRUCTION Ct Out of Service well C <br /> PUMP INSTALLATICN C SYSTEM REPAIR C. OTHER X Monitoring Well L�• <br /> soil borings <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 Industrial O Open Bottom C Manteca Oia. of Well Excavation 111CY1 Dia. of ')v-ii casino _ <br /> Fl Domestic/Private _ Gravel Pack Tracy Type of Casing_ Specifications <br /> 11 Public Cl Other 71 Delta Depth of Grout Seal Type of Grout cement <br /> I i IrnOaWn _Approx. Deptn pastern Surface Soul Installed by <br /> Repair Work Done a Type of Pump H.P. State Work Done_ <br /> Wed Destruction ❑ Wed Diameter Sealing Material i Depth <br /> Depth ?filler Material i Depth <br /> TYPE OF EPTIC WORK: NEW INSTALLATION ' i REPAIR/AOOITION i I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> available within 200 lest.) <br /> Installation wd e: Residence_ Comrnerc,al_ other <br /> Number of living units: Number of beorooms __ ---- <br /> Character of $off to a depth o feet: —7777,Y4111table depth <br /> SEPTIC TANK ❑ Type/MCapacity No. Comosrtrents <br /> PKG. TREATMENT PLT. C Method of Disposal <br /> Distance to nearest ell oundation Propertv Line <br /> LEACHING LINE 01 No. & Length of Total length/size <br /> FILTER BED . Cistance nearest W <br /> .. Well Fo anion Property Line <br /> SEEPAGE PITS I Depth Site Nuir a, <br /> SUMPS LI Distance to risarssc Well Foundation Property Line <br /> DISPOSAL ONOS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San own county ordinances. state laws, and <br /> rules and reguletions of the San Joaquin County <br /> Home owner or licensed agent's signature certrfies the following: "I certify that in the performance of the work for which this permit is issued. I shad not <br /> employ any person in such manner as to become suopct to , _Jmpensatlon laws of California... Contractor's hiring or sub-contracting signature <br /> csrtlfies the foaowrng: "I certrfy,that in the performance of the work for which this permit is issued. I shall employ persons subtect to workman's comtpensa- <br /> tion laws of California." <br /> The applicant must cad ler W regia ed inspec o is or wing on reverse side. <br /> Signed /// Title: Senior Geologist Date: 7/26/94 <br /> IJ^'�,/y�y��/,f//qI/I�. fOA EPA TMENT USE ONLY �/' � 2G� <br /> Application Accepted by ` '" "`" �l Dete v Area JJ <br /> Pit or Grout Inspection by 'Date Final Inspection by Cate <br /> Addifronai Comments' <br /> Applicant - Return all copies to: San Joaquin County Public Health Services S_ Q <br /> _avlr ^P^tal Health Permit/Services <br /> =45 Ir' San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> iNFEO AMOUNT DUE AMOUNT REMiT'ED �qSH RECEIVED dY DATE PERMIT N0. <br /> Q 1'a�ee 13A <br /> EM ti.z4 ir1W f"J 4� j I� I i i z�35 <br /> EM II.7e <br /> I <br />