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APPLICATION FOR PERMIT SAIROAQUIN COUNTY PUBLIC HEALTH PRVICES 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 Owner's Name Cargill Address P.O. Box 9300, Department 40 Phone 612 475-5422 s�py��n 4585 Pacheco Boulevard Contractoron Address Martinez, CA 94553 License No. 137422 Phone 510 372-9100 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L4 DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINESApprox 300' DISPOSAL FLO. NA PROP. LINEADDTOx 10' FOUNDATION -NA AGRICULTURE WELL NA OTHER WELL NA PITS/SUMPS Unk C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 6 inches Dia. of Well Casing L I.D. t Cl Domestic/Private I Gravel Pack ❑ Tracy Type or Casing Sch. 40 PVC Specification5'ee attached I1 Public (-1 Other FI Delta Depth of Grout Seal 10, Type of Grout Bentonite I I Irrigation 30'Approx. Depth I I Eastern Surface Seal Installed by Klienf elder Repair Work Done U Type of Pump NA H.P. State Work Done _ ( Well Destruction ❑ Well Diameter 2" 1.D. Sealing Material & Depth Depth 30' Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 II Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i F-C-7V`- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquf my ordinances, state laws, and rules and regulations of the San Joaquin County , r, �,. -•; e C.J.. Home owner or licensed agent's signature canities the following: "I certify that in the performance of the work7f3r which tftls permit m issued, I snail not employ any person in such manner as to become subject to workman's compensation laws of California." CoMractor'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 erpploy persons su6tacr w workman's compensa. tion laws of C lifor ' The applicant u call or all required inspections. Complete drawing on reverse side. Signed x Tine: Project Engineer Date: November 5, 1991 Tim Anenson FO DEP RTMENT USE ONLY Application Accepted by ,,ff �- Date I/ pArea ebb Pit or Grout In by \ 'u.,c�0'bf�. Data f Final Inspection by - r i (�! ��.hfi /[, -o L1 Date--t Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17 NO, EMIaQi(REV,i/net VI-�/ � /396 ^0O EM 4.7e / `( dA