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APPLICATION FOR PERMIT `/ `ar SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT E WIRES 1 YEAR VROM DATE ISSUED 7. (Complete in Triplicate) j��/�s�^' Application In hereby made.to San Joaquin County for a permit to construct and/or install the'vo`tk� 'M 'V Wdda�lbk �,I Tpis application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules .of San Joaquin County Public Health Services. Xob Address 1051 SPERRY ROAD City STOCKTON Lot Site/Acreage (209) 982-1500 Owner's Name JM MANUFACTURING Address 1051 SRRROAD Phone Contractor OWNER Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ' PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well El 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 11 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications S J/ j M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout C Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U 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 D R AIR/ADDITION Ll DES UCTION 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1 Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. 8 Length of lines Total length/size FILTER BED f=1 Distance to nearest: Well Fountion Property Line SEEPAGE PITS 11 Depth Sid Number SUMPS LI Distance to nearest: y1ell Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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: "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 of California." The applicant mu t c II r all required in ctions. Complete drawing on reverse sid Signed Title: Date: 7—Gl/ FOR DEPARTMENT USE ONL /'�q,��. Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO MOUNT DUE MOUNT REMITTED CASH RECEIVED BY DATE !/PPERMIT NO. EN 13-24111EV.,iMS, �,�p, 1 /,��C1 � "v 1-7—t ilyW15 EH'I�Ze N� l!