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SAN J` 4UIN COUNTY PUBLIC HEALTH Sa.wVICES 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 470 North Mair. Street City Manteca Lot Size/Acreage Owner's Name Ultramar. Inc. - Address 525 West Third Street Phone 209) 583-5571- Contractor — 1Contractor WeS eX Address P. 0. BOX 1664 License No. 552198 Phone 71-111 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Iff th tgdil&tj�iU9 DISTANCE TO NEAREST: SEPTIC TANK >50 SEWER LINES <50 DISPOSAL FLO. X50 PROP. LINE <50 FOUNDATION 150 AGRICULTURE WELL X50 OTHER WELL <50 PITS/SUMPS NLA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom El Manteca Dia. of Well Excavation$_i,nr-b Dia. of Well Casing N/A CI Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ N/A Specifications I'1 Public 1:1 Other n Delta Depth of Grout Seal 30 feet Type of Grout Cefnent/Berl r1itE 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 O Well Diameter Sealing Material 4 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 1 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, 1 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 u call for all r ui inspections. omplete drawing on reverse side Signed Title: Date: 3 FOR DEPARTMENT USE ONLY L� Application Accepted by Date Area (� O Pit or Grout Inspection by Date y Final Inspection by�n 1 Date �� Additional Comments: 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH (� . EM 13.24(REV.1/Mer '�� EH 14.20 lJ