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,1 SAN JOAQUIN"COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 2009, STOCgTON, CA-95201 <br /> PERMIT E%PIRES• 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San�Joaquin County for a permit to construct and/or install the Work herein described. This <br /> application is made in complia.nce'vith San Joaquin County Ordinance Nam 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> 4771 E. LIVE OAKItROAD City Lot Size/Acreage <br /> Job Address � <br /> � Owner's Name <br /> A. J. GAUTHIERI Address SAME 95240 Phone 368— <br /> 4500 E. FREMONT ST I <br /> a Contractor <br /> NOACK PUMP CO. Addresst License No.STOCKTON �_�Phone _ <br /> TYPE Of WELL/PUMP: NEW WELL C1 WELL REPLACEMENT/n DESTRUCTION o Out of Service Well Ll <br /> +- r OTHER O Monitoring Well C7 <br /> PUMP INSTALLATION ❑ v SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> i <br /> INTENDED USE TYPE OF-WELL ! PROBLEM AREA, CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C]'Industrial ' �' O Open Bottom ❑ Manteca Dia. of Well Excavation Specifications. <br /> IN Domestic/Private ❑ Gravel Pack O'.Tracy a F. Type of Other Casing_ <br /> i"1 Public 1-1 n Delta Depth of Grout Seal Type of Grout <br /> ,! <br /> _ ..Apprax_Depih;"i 1 Eastern Surface Seal Installed by <br /> i,l IrriOatian r 3HP State Work Done CE \ <br /> I Repair Work Done U Type of Pump' SUB H.P. v <br /> AND INSTALL <br /> Wall Destruction -❑ Well Diameter Sealing Material & Depth \ <br /> Depth Filler Material i Depth <br /> I <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRJADDITION E I DESTRUCTION l I availabe1lwthin 200 permitted if public sewer is <br /> Instaltatian will serve: Residence— Commercial— Other 1 <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet:' Capacity a <br /> SEPTIC TANK. ❑ Type/Mfg -- No:Compartments <br /> l <br /> PKG. TREATMENT PLT. 0 _ Mehod of Disposal ` <br /> w.-��"` " Pro ert Line', � C <br /> a Distance to nearest: Well Foundation p Y <br /> k <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED n Distance'to nearest: Weil Foundation Property line <br /> I <br /> .7 � <br /> SEEPAGE PITS 11 Depth Size Number ,. <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> ,.I_hefeby certify that I have prepared this application and the <br /> rules and regulations of the San Joaquin county <br /> Home owner or licensed agent's ft gnstlire certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in Ithe performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. <br /> tion laws of Calif ja." r <br /> The applicant t c I to a re i ns" C plate drawing on reverse side. <br /> DI L Title: L <br /> RETAIL SAES Date: 17 JUNE 1992 <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> _..� Date Z Area <br /> Application Accepted by "I <br /> Pit or Grout Inspection by Date Final inspection by <br /> Data <br /> i <br /> Additional Comments.- <br /> Applicant <br /> omments:Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 <br /> FEE AMOUNT DFJE AMOUNT REMITTED CASH RECEIVED BY ,DATE PERMIT'NO. <br /> j INFO <br /> r EH 13-241REV,k/A51 t <br /> E H 14.15 <br />