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APPLICATION <br /> SAN aOAQUIN COUNTY PUBLIC HEALTH �riRVICES <br />/ ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgPIRES 7. YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described This <br /> application is made is Health <br /> anceServices <br /> with San Joaquin County Ordlnance No 5l19 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health 9ervicee <br /> Job Addrass 4110 Industrial City Trac Lot Size/Acreage 57. n s <br /> Owner's Name MCKessan D Address 0 <br /> ne Phase _ <br /> San Francisco, CA 44104 680_ <br /> Contractor Gre —DrillingAddress 42 Rprr T]r p <br /> 3-chPP_c:nLicense No 485165 Phone 4442 <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT C7 <br /> DESTRUCTION C1 Out o! Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 14onitoring Kell <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial t0r2ng CTO n Bottom ❑ Manteca Ora o! Wei Excavation — 2n <br /> Domestic/Private <br /> �] f?w of Wen Casing <br /> C1 Gravel Pack K1 Tracy Type of Casing PVC g schedule 40 <br /> I f Public pecificauons <br /> IX OtherSand PaCki-1 Delta Depth of Grout Seal 8feet cement—bento xte <br /> ! i lnrpation 20_ Type o! Grout <br /> Aptxox Depth I I Eastern Surface Seal Installed by G <br /> Repair Work Done 0 Type of Pump HP <br /> Well Destruction Stats Work Done <br /> ❑ Well Diameter Scaling 1Satcrial i Depth i <br /> Depth Filler Material i Depth <br />.TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I {No septic system permuted if public sewer is <br /> Installation will serve ResidenceCommercial available within 200 feet ) <br /> � Other <br /> Number of living units Number of bedrooms <br /> Character of soil to a depth of 3 feet <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg Capacity. <br /> PKG TREATMENT PLT ❑ No Compartments <br /> Method of Disposal <br /> Distance to nearest Well Foundation <br /> � Property Line <br /> LEACHING LINE ❑ No b Length of lines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest Well Founaation <br /> � Property Line <br /> SEEPAGE PITS I f Depth Size <br /> SUMPSNumber <br /> Ll Distance to nearest Well Foundation <br /> DISPOSAL PONDS ❑ - Property Lyne <br /> 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 <br /> rules and regulations of the San Joaquin County <br /> 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 <br /> employ any person in such manner as to become subject to workman s compensation laws of California Contractor's hiring or sub-contracting signature <br /> certifies the If Pawl ify that in the performance of the work for which this permit is issued, l shall employ lion taws of i ornla " p y persons subject to workman s compensa <br /> The apple ant must call for I uired inspections Can <br /> drawing on reverse side <br /> Signed <br /> Title Manager Cor orate Environ <br /> /J�Fx� Date <br /> �7 1`'° �OR DEPARTMENT USE ONLY Affai s <br /> APPlrcatia ccepted by <br /> Pit or Grout Inspection by Date Area <br /> Date — Final Inspection by <br /> Date <br /> 0itfonal Comments <br /> m � <br /> Applicant - A q Y <br /> Return all copies to San Joaquin Count Public Health Services � <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE CK <br /> INFO AMOUNT REMITTED <br /> 3I4IAEy CASH RECEIVED By DATE <br /> PERMIT NO <br /> I/MSI <br /> 420 <br />