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- � • APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , 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 Port Road 21 City Stockton Lot Size/Acreage 4.21 -� owners Name Cargill Address P.O. Box 9300 Department 40 Phone (612) 475-5422 ��ki 4585 Pacheco Boulevard contractor n Address Martinez, CA 94553 License No. 137422 PhonJ510 372-910 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well XX DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINESApprOx300r DISPOSAL FLO. NA PROP. LINEA21?rox 10r FOUNDATION NA AGRICULTURE WELL --NA OTHER WELL NA PITS/SUMPS Unk INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1] Industrial ❑ Oven Bottom ❑ Manteca Dia. of Well Eanavatipn Inc Fe Dia. of Well Casing 2" I.D. Domestic/Private N Gravel Pack ❑ Tracy Type of Casing__Sch. 40 PVC SpecdicationsSee attached 'I Public Cl Omer 1-1 Delta Depth of Grout Seal 10t Type of Grout Bentonite Inigauon 30r Apiwoe. Depth I I Eastern Surface Seal Installed by Klienfelder Repair Work Done ❑ Type of Pump NA H,P. State Work Done _ Well Destruction ❑ Well Diameter 2" I.D. Sealing Material i Depth Depth 30' Filler Material L 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.l 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 1 Pi TREATMENT PIT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line \ SEEPAGE PITS I I Depth Sizs Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ I hereby cenify 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: -I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tionlaws of C icor Y - The applicant us call'f r all required inspections. Complete drawing on reverse side. Signed Title: Project Engineer Date: November 5, 1991 Tim An son t F DEP RTMENT USE ONLY Application Accepted by G Date ��// Area 5�3� Pit or Grout Inspection by Date Final Inspection by Dais Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Sery ealth 1E. Heizeeltoin Ave .,PH0 Box 2009,Permit/Services 1601CA 95201 p �� ZG• S� FEE -FA DUE AMOUNT REMITTED CK RECEIVED ay INFO CASM DATE PERM17 NO. 32IREV,irs 114-28 EE .-2e /-