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r SAN JUIN COUNTY PUBLIC HEALTH S..eVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. few, Job Address � �� Sri„+11X Ghe+0t2�e l..Arte City Lc Lot Size/Acreage Owner's Name _ARCO PP1tAULCAS CO- Address P.n Box Sol{ Phone )5- —210`1 Contractor Address ?0goxQ6, 12#a Clt.S�C, "ticense No.s -5B hone qiL Ov TYPE OF WELL/PUMP: NSW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ' Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK >50 SEWER LINES 4 S0 DISPOSAL FI-D.2-5-0_ ROP. LINE �K`10 c.4tc„ FOUNDATION AGRICULTURE WELL'>5-70 OTHER WELL :Z� PITS/SUMPS >_2> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation:--IQ=T Dia. of Well Casing 1] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ PVC Specifications I'1 Public Cl Other 171 Delta Depth of Grout Seal 24 abo✓t SCAVC+.Type of Grout 3erf:617,k I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by drid Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & 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.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ,'SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify 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- tion laws of California." The applicant m t all fir all qui in ctions. Complete drawing on reverse side. t� Signed X Title: Pr-6'1 P t+- Date: � ��V 7 OR DEPARTMENT USE ONLY 2 Application Accepted by `� Date Area 3G Pit or Grout Inspection by iAA44—7"V"* Date ! Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services /t Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED / CK /RECEIVED BY PATE PERMIT'NO. . EH 1211REV.rresr t�C, // ^ EH t4114-26 [[[ill CCCIII