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APPLICATION FOR PERMIT' SAN JOAQUIN COUNTY PUBLIC. HEALTH, SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA- 95201 (209) 468-3447 J # PERMIT MIRES ,1 MAR PROM DATE IS59ED � (Complete in Triplicate) i Application is hereby oade,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 the Rules and Regulations of San {} Joaquin County Public Health Services. /Job Address 1533 EAST LINDSAY ST City STOCKTO $i eage x ( SMART) Owner's Name STOCKTON METROPOLITMdress 1533 EAST LI&M.lu TRANSIT DISTRICT p� /� Contractor_ MARTECE USA -IN Address Address $540 YOUNGER CR _DR_. Licerl f Phone 800E TYPE OF WELL/PUMP: NEW WELL O WELL. REPLACEMENT ❑ DE t of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0 `�.LNlonitoririg Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, OP.�,LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS . i INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS # 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q Public l-1 Other ❑ Delta Depth of Grout Seal Type of Grout M Irrigation __..Approx. Depth ❑ Eastern Surface Seal Installed by. k Repair Work Done U Type of Pump H.P. State Work Done _ Weil Destruction 0 Well Diameter Sealing Material .i Depth Depth Filler Material 4 Depth TYPE. OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION CI (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 F Character of $oil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity -- — - No. Compartments i PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS 11 Depth Size Number SUMPS ` CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F 1 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 N rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the,perlormance of the work for which this permit is issued'; I shall not employ any person in such manner as to become subject to w rkman's compensation laws of California." Contractor's hiring or subcontracting signature i certifies the following: "I certify that in the performs soft work for which this permit is issued, I shall employ persons subject to workman's compsnsa• tion laws of Califoml i The applicant mus for all re ins ti Co ate drawing on reverse side. SignedTitle: Vice--President Data: 03/29/91 l Donald K. Litch E FOR DEPARTMENT USE ONLY I I Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES G ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN,- P O BOX 2009, STOCKTON, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMll'N0. . EH 13.24 IREV.1 eSr EH i{•2a3,