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APPLICATION FOR PERMIT it SAN QUIN COUNTY PUBLIC HEALTH S. ICES ENVIRONMENTAL HEALTH DIVIS '.. ON 1601 E . HAZELTON AVE . , PHONE ( 20U ) 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services , Job Address 4405 PACIFIC AVENUE City STOCKTON Lot Size/Acreage UNKNOWN Owner's Name VINTAGE CAR WASH Address 2020 STANDIFORD AVE . , MODESTO , CAPhone 209 523 - 8100 Contractor TREATEK INC . Address 2701 E . HAMMER LN # 103 License No. 599838 Phone ( 209 ) 472 - 20 TYPE OF WELL/ PUMP : NEW WELL O SOIL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTAL TION ❑ BORING X SY TEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK1000 ' SEWER LINES 100 DISPOSAL FLD. N/A PROP. LINE 20 FOUNDATION 30 ' AGRICULTURE WELL N/A OTHER WELL N/A PITS / SUMPS 20 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 4 " Dia . of Well Casing N/ A n Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing - N/A Specifications N/A I '1 Public 1:1 Other n Delta Depth of Grout Seal 15 ' MAX Type of Grout CEMENT I I Irrigation _. Approx. Depth 11 Eastern Surface Soul Installed by TREATEK Repair Work Done U Type of Pump H , P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth CEMENT — 15 ' MAX Depth Filler Material & Depth TYPE OF SEPTIC WORK : NEW INSTALLATION 1 I REPAIR /ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet. ) Installation will serve: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to 4 depth of 3 feet: Water table depth SEPTIC TANK . ❑ Type/ Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ 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: "1 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 of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X �� Title: PROJECT MANAGER Date: 10/ 15 / 91 F R DEPARTMENT USE ONLY Application Accepted by Date �0 / Area �!O Pit or Grout Inspection by ate /�, Final/alInspection by Date Additional Comments: 5jhllao /I/ sBi A—50S Applicant — Return all copies to: San Joaquin County Public Health � Services , zeltocnment , Health Permit/Services Py 1601 E. Hazelton Ave . , P 0 Box 2009 . Stockton, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED /CASH RECEIVED BYaja) EH I3 ]I IPEV. i / xslEH 7x.zefZ 03