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APPLICATION SAN J..-AQUIN COUNTY PUBLIC HEALTH :� VICES L, HEALTH DIVISIOV 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 Main Street city Manteca Lot Size/Acreage 22, 500 sq.ft. Ultramar, Inc. 525 West Third Street, Hanford CA 93230 209)583- 3 Owner's Name Address Phone Contractor Woodward Drilling Address P.O. Box 336, Ri oVi std,Liiccense No. (C-57)581639 Phone (707)374-4300 TYPE OF WELL/PUMP: NEW WELL It WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK >50 ft SEWER LINES >50 ft DISPOSAL FLO. >50 ft PROP. LINE 5 f FOUNDATION >50 ft AGRICULTURE WELL > ft OTHER WELL > ft PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom M Manteca Dia. of Well Excavation 10 in Dia. of Well Casing * Domestic/Private )7 Gravel Pack ❑ Tracy Type of Casing SCh 40 PVC Specifications Il Public n Other n Delta Depth of Grout Seal 30 ft Type of Grout Neat C3TEnt I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by tremie pipe Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth neat CAnP_nt Depth Filler Material i Depth neat Cement TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOITION I I DESTRUCTION I 1 INo 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 LineED SEEPAGE PITS 11 Depth Size Number 1 1992 SUMPS LI Distance to nearest: Well Foundation Property L' 4.COONTY DISPOSAL PONDS O H T14 SERWCES I hereby certify that 1 have prepared this application and that the work will be done in accordance with S a y [c -6 es, 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 s call for all rsqu)'ra�d ins lionnss.•Complete drawing on reverse side. Signed X ,e T r �""`-�� Title: 14 Date: all 7AJ Richard H. Alden_277 , FOR DEPA l �UfJ Geologist 9 12-17-?91rt Application Accepted by f r, (/ Date 4 Area �`3 v Pit or Grout Inspection by-7771 nate 7 ( � Final Inspection by Data Additional Comments: 0 Applicant - Return all copies S Joaq n County Pu Sc alth Sery ces finvironmental Health Permi /Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE f CK INFO AMOUNT) DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH t}24IREV.1/0161 P—a-1i `�� l/ � 1,4-2-o�+ +-� EH 14.27 - r�