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y y APPLICATION 7412 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES n � ENVIRONMENTAL HEALTH DIVISION (� 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i PERMIT EXPIRES-1 YEAR FROM DATE ISSUED R Kh .(Comp1ete Jn Triplicate) W ` r � r . a, Application is hereby made ule to San Joaquin County for a permit to construct end/or install t- Rk herein described. This application is made in compliance with San Joaquin County Ordinance no. 549 and,1862 and the ules and Regulations of San Joaquin County Public Health Services. 5381 CANAL RD. City TRACY Lot Size/Acreage Job Address KEN P O M B O Address 6381 CANAL RD. Phone 835-9761 i3525 PELANDALE AVE .License No. 290813 phone 545-1185 Contractor HENNINGS BROS. DRILL.Address WWELL M WELL REPLACEMENT F) DESTRUCTION [A out of Service Well ❑ TYPE OF ELL/PUMP: NEW OTHER ❑ Monitoring Well PUMP INSTALLATION 13 SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK 1001 SEW€R LINES 100 , DISPOSAL FLO. PROP, LINE FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 611 _ Dia. of Well Casing El Industrial ❑ Open Bottom_ C1 Manteca Dia. of Well Excavation 1 (�O S C h Kl Domestic!Private CX Gravel Pack �3 Tracy Type of Casing_. P V C Specifications-- ,1 Depth of Grout Seal 10 0 r Type of Grout 8 N T NIT E V1 Public Cl Other 171 Delta 11 Irrigation Approx. Depth I I Eastern Surface Seal Installed by H E N N I N G 5 BROS . DRILL I N G C O . Rep if Work Done U Type of Pump H.P. State Work Done C Well Diameter 6" Sealing Material & Depth R F N Well Destruction � Depth., Filler Material &.Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I afvo septic sy t 20em 0 fgeited it public sewer is l � - i�• 9. ,},, ,? •.>-, j..j 3.�: is j t: 1 lr.t I;l ,nmi'2r; f Installation will server Residence Commercial Other Number of living units: Y Number of bedrooms r �rr;r f If C cr,r'oa Water fable depth Character iof-soi�do a depth, f-3 feet: SEPTIC TANK [3 Type/Mfg Capacity Na. Compartments PKG. TREATMENT,PLT.❑ Method of Disposal ''Distance to nearest: `' Well Foundation Property Line length/size s leg LEACHING LINE Cl Na. & Length of.lines Tote . FILTER BED ❑ Distance to nearest: Well Foundation Property Line L SEEPAGE PITS 11 Depth Size Number :- N LI Distance to nearest: Well Foundation party", SUMPS Pro Line's`"` 4 y DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and.that the work wi11 be done in accordance with:Sari:foaquin 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 workmen's compensation laws of California." 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,I shall employ parsons subject to workman's comp ensa• er tion laws of California. The applicant must call for all required inspections. Complete drawirEg on reverse side. \yQ Date: SEPT. 2 ,_1992 Signed K Title: I FO DEPAR MEN USE ONLY Application Accepted by Date Z Area Pit or Grout Impaction by Date Final Inspection by Date 5a la— amu. c! IA —/S/ C/ 1 /10 O1cC Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ��e+• T`Y` Environmental Health Permit/Servicesa]� f" . :i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT Ou OUNT REMITTED RECEIVED BY DATE PERMIT'NO. INF o ♦ EN 13.24 IREV. EN 14-21 e I .