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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 470 North Main Street City Manteca Lot Size/Acreage Owner's Name Ultrarrlar, InC. __ Address 525 West Third Street Phone 209 583-5571 Contractor Weste WestAddress P. O. Box 1664 License No. 552198 Phone 371-1118 TYPE OF WELL/PUMP. NEW WELL Q WELL REPLACEMENT M DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 'i9bkiM DISTANg TO NEAREST: SEPTIC TANK >50 SEWER LINES <50 DISPOSAL FLO. >50 PROP. LINE <50 FOUNDATION >50 AGRICULTURE WELL 250 OTHER WELL--.: 50 PITS/SUMPS NLA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial Cl Open Bottom RI Manteca Dia. of Well Excavation R ;nch Dia. of Well Casing N/A Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— N/A Specifications I'l Public Ci Other n Delta Depth of Grout Seal 30 feet Type of Grout cemnt/Bentcaite I I Irrigation —Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material 3 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I 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. 0 Method of Disposal r Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS EI 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 of subcontracting 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 Tor all r ui inspections. omplete drawing an reverse side Signed X Title: Date: 3 FOR DEPARTMENT USE ONLY Application Accepted by Date �� ` Area r O Pit or Grout Inspection by T/`r` Date y Final Inspection by 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 CASH RECEIVED BY DATE PERMIT NO. INFO • EH 13.241AEV.��HSI EH 1 4.2a VV LL a.cip I