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APPLICATION FOR pERidl SArlf' JOAQUIN COUNTY PUBLIC gF,AI,TH gFRVICES ENVIRONUMTAL HEALTH DIVISION 1601 R. HAZELTON AVE. , PHONE (209)488-3420 P O BOX 2009, STOCKTON CA 95201 t I T E%PI Rg 1 YEAR FROM (COmplete in Triplicate) Application is hereby made to San Joaquin County for a permit to construclt and/or install the work herein described. This application is made in cOW11anee with San Joaquin County Ordinance No. 549 and '1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 Job Address City Lot Size/Acreage Owner's Name Van Den Bergh FoodSAddress 1400 Waterloo Rd, Stockton, CA Phone(209) 466-9580 Ij Contractor IT Corporation Address 4585 Pacheco Blvd. , Mart!COA No _1 _Phone 510 372-91 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION —ZQ- AGRICULTURE WELL OTHERi�WELL�51 _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation- pia. of Well Casing 4 inch C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications I'I Public IXl Other F� Delta Depth of Grout t�t Seal % . A .. Type of Grout t I I Irrigation 2.(L Approx. Depth 11 Eastern Surface Seal , ' IT- ror-po-atinn rr,,installed by Repair Work Done ❑ Type of Pump none H.p. none '1k StateIF Nr Done f Well Destruction O Well Diameter 4^i nC� Sealing Material i Depth'aSpha 11 L, ConCr vapor monitoring Depth 20 Filler Material s Depth SOi1 12' gravel 8' TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I i DESTRUCTION 111'I INo septic system permitted if public sewer is ` available within 200 feet.) Installation will serve: Residence^ Commercial— Other 9 Number of living units: Number of bedrooms Character ofi so I to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity i No. Compartments PKG. TREATMENT PLT.❑ i Method of Disposal Distance to nearest: Well Foundation Property Line it LEACHING LINE ❑ No. a Length of linesTotai length/size FILTER BEO ❑ Distance to nearest: Well FoundationProperty Line i; SEEPAGE PITS I I Depth -Size Number - ruunaauon :,uercy DISPOSAL PONDS El } 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 I# 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 Calif ornia.'• Contractor's hiring or sub-contracting signature f certifies the following:"I certify that in the performance of the work for which this permit is issued, 1 sF�tall employ persons subject to workman's compensa- tion l tion laws of California." ,1 I The applicant st call for ad inspections. Complete drawing on reverse side. Signed Title: A-_TEcr M4W44rQ:1 fCo&PvIC,grlo►.IDate: a a 3 S } / FOR DEPARTMENT USE ONLY Application Accepted byDate /� / �Q G 'I Area i Pit or Grout Inspection by Date Final Inspection by pate Additional Comments: !'I Applicant - Return all copies to: San Joaquin County Public Health ij Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEEVED BY PATE PERMIT NO. INFO E„ -�(REV.iinS) �9 8y