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7t II APPLICATION FOR PBRiIIT .,. SAN JOAQUIN COUNTY PUBLIC-HEALTHIfSERVICES ENVIRONItENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 `` P 0 BOX 2009, STOCKT0N, 11CA 95201 1. I 'f� PERMIT EXPIRES 1 YEAR FRQM 1iDATE ISSM (Complete in Triplicate).! I Application is hereby mede,to Sam Joaquin County for a permit to constructl�and/or-install the work herein described. This application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San f Joaquin County Public Health Services. II, j Job Address 1705 N. Broadway City SJocktoi] Lot Siz'e/Acreage I macer•, NameGeor a Schuler Inc Address 1705 .N. Broadday `__ _ Phone 948-5500 II � Contractor_ Osterberg & StewarAaress_ 2741 River Road,_ Modestose No. 445670 Phone 537-5767 I, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl ;; DESTRUCTION ❑ Out of Service Well ❑ ^ OTHER ❑ Monitoring Well 0 SYSTEM REPAIR PUMP INSTALLATION DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES jDISPOSAL FLD. PROP, LINE I A AGRICULTURE WELL OTHER WELL PITS/SUMPS _FOUNDATION , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS See Work Plan - 11/25/9 0 Industrial ❑ Open Bottom a Manteca Dia. of Well Excavation 17r Dia. of Well Casing 211 I �- it Schedule 40 F-] DomesticlPrivats ❑ Gravel Pack � Tracy Type of Casing !PVC Specifications { f'1 Public 11 Other CT Delta Depth of Grout Seal _E1 rOX 50r Type of Grout Neat Cement I I Irrigation 70 Approx, Depth I I Eastern Surface Seal Installed by Repair T II � C ep Work Done L3 Type of Pump H.P. State Work pone � U Well Destruction ❑ Well Diameter 21 1 Sealing lifaterial i Depth it li Depth Piller Material i Depth .I1. II TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAiA/ADDITION I I DESTRUCTION I Il!iiNo septic system permitted it public sewer is 11 Iavaiiable within 200 lest.) Installation will serve: Residence_.—,— Commercial Other Number of living units: Number of bedrooms ; e I {' Character of sol to a depth of 3 feet: it 'I Water table depth rr SEPTIC TANK. ❑ Type/Mfg Capacity ' No. Compartments ' PKG. TREATMENT PLT.Q ji Method of Disposal (1 ;I Distance to nearest: Well Foundation I Property Line nl LEACHING LINE ❑ No. b Length o1 tines ;Total length/size r p FILTER BED ❑ Distance to nearest: Well Foundation Property Line lr SEEPAGE PITS 11 Depth Size Numbai ` SUMPS Ll Distance to neatest. Well Foundation II Property Line DISPOSAL PONDS ❑ II Ij i I hereby certify that I have prepared this appkication and that the work will be done in acconiance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County it Home owner or licensed agent's signature certifies the following: "I certify that in the perlor it ance 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 subcontracting signature 1 certifies the following: "I cern t in the riomtancs of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif �I II The sppkicant tAftAll ail 'in Complete drawing on reverse side. I!1 ! I Vice Presidents 6/16/93 i Signed Title: Dale: FOR DEPARTMENT USE ONLY: II 11 rL6,0C Application Accepted by I;Diets Area I Pit or Grout Inspection by Date Final Inspection by i' Date Z Additional Comments: A i II 1 Applicant - Return all copies to: San Joaquin County Public Health, Servl. es Environmental Health Permit/Services 1 445 N San Joaquin, P O Box 2008,'IStkn,II;1GA 95201 )FEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY.I� DATE PERMIT NO. . £H144- V.ii�Sr �V 4�� i� I� 1(j' 'Ei/7 ! Nb-b EH t6m