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APPLICATION SAN JO. JIN COUNTY PUBLIC HEALTH SE1 ICES \ � ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN , PHONE ( 209 ) 468 -3420 P 0 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 2050 Fast Frp rine Strppi- City ¢eru�ktonton Lot Size/Acreage 2 S aCr'eS Owner's Name Apache Plastics Address 9050 East Eteationt Street Phone ( 209 ) — 4156 256/< ?',4ssoc1u7Lc s Inc . C57- 4Io%¢Z 5�) 4& - 4C , Contractor Pd it resso1 l AlR1 Tin . Pl easantnncense No . �s Phone _ TYPE OF WELL/ PUMP: NEW WELL M WELL REPLACEMENT Ll DESTRUCTION RI Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERMonitori Well R/adose Wel 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 LXIndustrial ❑ Open Bottom ❑ Manteca Dia . of Well Excavation Dia . of Well Casing ❑ Domestic / Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications I '1 Public I:1 Other f1 Delta Depth of Grout Seal Type of Grout r I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by k Repair Work Done ❑ Type of Pump H , P, State Work Done _ t Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK : NEW INSTALLATION I I REPAIR / ADDITION I I DESTRUCTION I I ( 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 ❑ Type/ Mfg Capacity. No, Compartments PKG , TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ 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 subcontracting 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 t�olmpepfIsa-, / tion laws of California. " 11 2// UE'Jf &CPLr The applicant st. %. i for all an coections. Complete drawing on averse side. See Ata h Sketches Sheets 1 &2 �P � �iarrL: e�i�frL� �t�YuiCBS Signed % ' Tice: � � � � '+ Qe Date: October 8 , 1991 ' FOR DEPARTMENT USE ONLY Application Accepted by L 1�� Date � Area 01 Pit or Grout Inspection byDate / o Z➢ Final Inspection by I Date 4 Z Additional Comments: S i Applicant - Return all copies to : San Joaquin County Pu lie Health Services Environmental Health Permit/ Services 445 N San Joaquin , P O Box 2009 , Stkn , CA 95201 FEE I INFO AMOUNT DUE IAlM�{O��/UNT REMITTED 1 CCAAyS''H) ECEIVED BY DATE P,11111117 NO. . EM I3.14 IREV. iral) , ^ �� / I r ' m �O q' — ylt "`—`C ` EH 14m }