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r ;{ APPLICATION FOR PERIL I T ' SAIIOAQUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-342.0 P 0 BOX 2009, STOCKTON, CA 95201 I PMWT EXPIRES 1 YEAR FRQM DATE I S UED (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 vith San Joaquin County Ordinance No. 549 and 1662 and the`Rules and Regulations of San Joaquin County Public Health Services,(-2 Job Address G� City S t O C k t O n Lot S1 ie/Acreage Stockton Plating Inc. address 104 E . Scott Street Phone- , 948-1101 Owner's Name Oil Equipmen SFEcT��')►, Pa Box 9 hoc. rD . 51 �Z�g 209- G�?1 Contractor Service t fddfl�rs` F e a 5s icense No. Phone754- 1805 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)p llMonitoring Well DISTANCE TO NEAREST: SEPTIC TANK N A. SEWER LINES 50+ DISPOSAL FLO. PR�?Lf E Boring *see ALt aChmPnrs FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation $ C, � , Dia. of Well Casing r'l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications I'1 Public 1:1 Other In Delta Depth of Grout Seal Type of Grout I I Init}ction ^Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitled 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 tattle depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest: Wall Foundation Property Line 1 SEEPAGE PITS I I Depth ° Size Number SUMPS L1 Distance to nearest: ?i Well Foundation Property Line - DISPOSAL PONDS ❑ f hereby cenify that I have prepared this application iand 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 jn such manner as to become subject to workman's compensation laws of California."Contractor's hiring or suacontracting 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 laws f-Calif The ap cant u call, or alf d ' spec s. Complete drawing oryr arse side. Signed f ll: Title: Vr Date: } FOR DEPARTMENT USE ONLY Application Accepted by t -.E kar Date ` Area Pit or Grout Inspection by Data Final Inspection by /,J, Date ^ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services', Environmental Health Permit/Services 1601 E. Raseltoo Ave., P 0 Box 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7,NO. EN 13 24 t M v