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t ' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUAP (Complete in Triplicate) i Application is hereby ts& to San Joaquin County for a permit to construct and/or install the work herein described. This application ismade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address 23840:�<BERG RD. City TRACY Lot Size/Acreage Owner's Name GROUT BUSTERS Address 23696 BERG RD. Phone 835-1413 Fit q-UT"--+- Contractor MAI N-GL BROS, DRIU Address_3525 PELANDALE AVE . License No. 290813 _Phone -1185 TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT X1 DESTRUCTION Out of Service',Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 100 t SEWER LINES 100 r DISPOSAL FLD. PROP. LINE --15 t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS g{� JC= 22,T f� Industrial ElOpen Bottom C) Manteca Dia. of Well Excavation Dia. of Well Casing fX Domestic/Private Xl Gravel Pack N Tracy Type of Casing P V r. Specifications--160S C h - i'1 Public L] Other Ll Delta Depth of Grout Seal 100 , Type of GrouR NTDNITE- _- - CIO I I Irrigation —..Approx. Depth II Eastern Surface Seal Installed by HENNINGS BROS. DRILLING CO. , INC. Repair Work Done 0 Type of Pump H.P. Sta�Ie or Rp _ Well Destruction XD 'Well Diameter 611 f Sealing Material i Depth NT.O � I 1 .,Depth Filler Material & Depth .aTA7errfe �.�'il • --- TYPE OF SEPTIC-WORK:' NEW'INSTALLATION I I REPAIR/ADDITION I l DESTRUCTION I I iNo septic system permitted it public sewer is available within 200 feet.] h�rSs SZII -• .,'� t rl,. I2 f3 Installation will serve:'- Residence I. 'Commercial_ Other ` Number of living units: Number of bedrooms Character fof-soil. 6'e'dspth.of 3 feet:. Water table depth 8 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/sire FILTER BED ❑ Distance to nearest: Well Foundation Property Line e, SEEPAGE PITS 11A Depth Size Number N. ,. '�srOlJIFF SUMPS LI Distance to nearest: Well Foundation Property Linei,'lc- ri:- : . I i h�i� CC) INC DISPOSAL PONDS ❑ I hereby certify that I have.prepared this application and that the work will be done in accordance with.SanUo`dquin 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- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. hh Signed Title ��.. /1 _ Date 9-2-9 2 FOR DEPARTMENT USE ONLY p Application Accepted by ! Date L Area Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: 2 Z> C-1, if [ Applicant - Return all copies to: San Joaquin County Public Hea th Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 . FEE AMOUNT DUE AMOUNT REMITTED � RECEIVED BY DATE PERMiT'NO. r 4IN Jq' + EH13-24(Rev.Ii e$) a EH 14.26 /v 0 Tr / Z'—