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APPLICATION FOR PERMITLV m . SAN AQUIN COUNTY PUBLIC HEALTH tVICES ENVIRONMENTAL HEALTH DIVISI 1601 R. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EXPIRES 1 YEAR FROM DAIR ISSVJM.i, (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in cmwliance vith San Joaquin County Ordinance No. 549 and 1862 and the'Rules and Regulations of Saar Joaquin County public Health Services-(—2 �� Job AddressS t O C k t o n City Lot Size/Acreage � Owner'aName tockton Plating Inc . Address 104 E . Scott Street Phone 948-1101 Oil E u i men SFEc�2 avwt Pe Box--95-6 1-C C D 2 0 9- q P j, 5'1 ZZ�8 [ 7r Contractor Service t. �dlris°s` r icense Na Phone754-1808 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well ❑" PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1monitoring Well C DISTANCE TO NEAREST: SEPTIC TANK N' A� SEWER LINES 50t DISPOSAL FLD. PR OL1r Boring (� See AttBCl'1I1entS_. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial .0 Open-Bottom ❑ Manteca Dia. of Well Excavation. ..e ineh— Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Wall Destruction ❑ Well Diameter j. Sealing Material i Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I t INo 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 ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal = Distance to nearest: Well Foundation Property Line LEACHING LINE L-1 No. 8 Length of lines Total length/size FILTER BED 0 D"utance to nearest., Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest-. Welt Foundation Property Line - DISPOSAL PONDS D I hereby cenify 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 cenify that in the performance of the work for which this permit is issued, I shall not employ any parsenlft such manner as to become sub)ect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws f Calif The ep "cant u teff or al d_spec' s. Complete drawing or�r erre side. 1 Signed 1 �l. Title• Date 5ZZ/` l FOR DEPARTMENT USE ONLY Application Accepted by Date r 4k Area Pit or Grout Inspection by Date L Final Inspection by Date u, Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services � 100 �t 1601 E. 'Hat:elton Ave., P 0 Box 2009. Stockton, CA 95201FEE y INFO Ki AMOUNT DUE AMOUNT REMITTED CASN RECEIVED BY DATE PERMIT,NO. y 1 r .,7 E++57 24 fREV fins Al0 .0 G V -y r ,.,,� ��y..,l��` ��`•r.�,'. �r titer-'