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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 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 25600 CHRISMAN ROAD WaL# 8 City TRACY Lot Size/Acreage 445 ACRES f 1 Owner's Name DEEIIJZE DISIRI=CN WASTAddress 25600 MEMW ROAD Phone(209) _ — ALL, R4ERICN WATER_SUFF'LY 09yoE-or X/ A2. aso/6o 0 602 381-8877 oontr`alc or Address 4120 NORTH 2OIH SIREEI' S= Qicense No. 607%4 �?0'Phb — TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Xl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR M OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK WA SEWER LINES 640' DISPOSAL FLO. N/A PROP. LINE L52r FOUNDATION 160' AGRICULTURE WELDy OTHER WELL-!(—)0' PITS/SUMPS NLA. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [ (p� Industrial ❑ Open Bottom (� Manteca Dia. of Well Excavation Ufa �Wefi:�ssingl8a 40 %0/1 " Ca Domestic/Private 0 Gravel Pack r Tracy Type of Casing S= Specification " Il Public Ci Other n Delta Depth of Grout Seal 4-400 Type of Groi9=SMR-CEMR9 I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed b PML. WATFR Repair Work Done LJ Type of Pump H.P. State Work Done k Well Destruction ❑ Welt Diameter 16" — 18" Sealing Material i4.Depth 1)11(71 C�_cACV C'FTA M fC� Depth 954' Filler Material & Depth SILICA FN�D TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ! I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) d Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k PKG. TREATMENT PLT. ❑ Method of Disposal r r Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size t-. FILTER BED ❑ Distance to nearest: Well Foundation i 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,,spust call for all re uir d inspect'on Comp l to drawing on reverse side. Signed Title: S(.8 //1� y, if, �Date: -1( --92 FO DEPARTMENT USE ONLY /: Application Accepted by Date 10 Area Pit or Grout Inspection by Date Final inspection by Date D If Z r R f Additional Comments: Applicant - Return all copies to: San Jouquin County ublic Health Services � � •!�Yj` G 'll, 4 00 Environmental Health Permit/Services `! 0'rrFEE _ / 45 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 r OI c AMOUNT DU AMOUNT REMITTED CK R RECEIVED BY DATE PERM11'ND. + EH 13.24{AEV.i i n 51EH i4 / / c/