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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San ? Joaquin County Public Health Services. `Job Address _5405 East Fop-;2iano _Trane City Lot Size/Acreage 138 acres Gertrude M. W- eber Trust k wner's Name Address 3757 College Avenue, Sa.cto. Phone (916) 44113-156 3252 Polk Way, Stockton, CA � � ontractor arne� dry, Tnc License No. �___,Phone(209) 944-9 55 9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ out of Service Well ❑ f PUMP INSTALLATION ❑ SYSTEM RE AIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION CULTURE WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WEial ❑ Open Bottom Jr:0 M nteca Dia. ell Excavation Die. of Well Casing ( � C] Domestic/Private ❑ Gravel Pack ❑ T acy 7 pe of Casa Specifications I'1 Public C] Other �l Ita Depth of Grout Seat _ Type of Grout—_ I i Irrigation �.Approx. Depth l I E stern Surface Seal installed by Q Repair Work Done L7 Type of Pump H State Work Done_ Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTIONlNo septic system permitted if public sewer is [� vailable within 200 fast.I 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 SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The appitcan or all u' ions. plate drawing on reverse side. �Signed Title: Vice-President Date: ATDrii ,7 , 1993 1 F DEPARTMENT USE ONLY Application Accepted by —� `+ � Date '1`-7-93 Area Pit or Grout Inspection by Date Final Inspection by Date S[e Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH ' RECEIVED BY DATE PERMIT ND. 4 Q • 1 (REV.r i R s1 S � � � �' �E14 M 14-M I-m