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If SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN .JOAQUIN, 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 8842 S H U L T E RD . City TRACY Lot Size/Acreage Owner's Name L U C I L L E FRY Address P .O. BOX 56 , M A N T E C A phone 239-1242 Contractor HENNINGS BROS. DRILLAddress 3525 PELANDALE MOD 953515license No. 290813 Phone 545- 1185. TYPE Of WELL/PUMP: NEW WELL [_l WELL REPLACEMENT n DESTRUCTION I Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I_} industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ['I Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ Specifications I'] Public 0 Other fl Delta Depth of Grout Seal Type of Grout I i Irrigation -_-._Approx. Depth I I Eastern Surface Seal installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction Well Diamet �11 Sealing Material & Depth Depth Filler Material & 'Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.) iInstallation 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 I 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 [ I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t 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- tion laws of California." The applicant must call for all required inspections. Complete awing on reverse sod . Signed Titl : wilia Date: MAY 17 , 19 9 3 FOR DEPART NT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by ��/lJ Date Additional Comments: t / Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. . EH 13-24[REV. 51 Eli 14.26 i fff vvv