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I APPLICATION FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 R rROM DATE ISaUM ) (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or insta].1 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 Joaquin County Public Health Services. V4ob Address 1051 SPERRY ROAD City STOCKTON Lot Size/Acreage Z 2 0 Ae. JM MANUFACTURING1051 SPERRY ROAD STOCKTON (209) 982-1500 1 `owner's Name Address Phone I ` antraclor OWNER Address L-icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ID Open Bottom © Manteca Die, of Well Excavation Dia. of Well Casing 'p 0 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications In Prlblic I'1 Other ❑ Delta Depth of Grout Seal Type of Grout G Irrigation —Approx. Depth ❑ Eastern Surface Seat Installed by .Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION C1 DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) 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., ❑ Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well f=oundation Property Line SEEPAGE PITS I I Depth Sire 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, an 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, I shall employ persons subject to workman's compensa- tion Iowa of California." The applicant must for all requir inspections. Complete drawing on reverse std _ r ` Signed t Title: Date; DEPARTMENT USE ONLY Application Accepted by ; Date &,—Z-2 "` Area Pit or Grout,lnspiction by Date Final Inspection by Date — Additipnal Comments; Applicant - Retui.0 all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 FEEINFO AMOUNT DUE OUNT REMITTED ASH V RECEIVED BY DATE PERMIT NO. . EH 13.24IFIEV.i/xkr R��b6 EH;..m t o. v�0