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APPLICATION SAN JUAQUIN COUNTY PUBLIC HT4LTH1 VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 . PERMIT E� gES YEAR FRO DATE ISSUED ' (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or instan the work herein described This application is made in compliance with San Joaquin County ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County public Health Services. I • Job Address 4110 Industrja3 Way City Tracv Lot Size/Acreage 57-500 G _f t ' Owner's Name McKesson Drug ro Address Qne hast R _ cr ?ASO Phone 1415) 9 3-7998 San Francisco, CA 94104 680_ Contractor GreggDrilling Address 42 Rprrv�_ ,liachec.o—. License No 485165 Phone 4442 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Weil ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS & Industria!Y30171itoring❑ Open Bottom ❑ Manteca Dia of Well Excavation - Oia of Well Casing ter n Domestic/Piware C1 Gravel Pack M Tracy Type of Casing PVC Specifications Schedule 40 ' 1 1 Pubitc (X Other Sand Packn Delta Depth of Grout Seal 8feet Type of Gtoutcement-bentor ite I I lmosteon 20-2-5.1 Approx Depth i I Eastern Surface Seal Installed b5+ Greg$ Drilling Repair Work Done U Type of Pump HIM State Work Done_ Well Oestraction ❑ Well Diameter Sealing Material i Depth ' Depth Piller Material 4 Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No sapric system permitted if public sewer is Installation well serve Residence Commerciai_ Other available rvethen 200 feat ) }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 Cl No A Length of lines Total length/sue FILTER BED ❑ Distance to nearest Well Foundation Property Line ' SEEPAGE PITS i I Depth Sire Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby eerTefy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat rules and regulations of the San Joaquin county e laws and ' Home owner or licensed agent's signature oertifiee 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}Ofrnim fy that in the performance of the work for which this permitot is issued I shall em tion laws of P Y persons sublact to workman s compensa The appl antt can for I uered inspections Complete dravving on reverse side Signed Manager Corporate Environ. rare Date 3/ y? ' ��✓ f7. ��x OR DEPARTMENT USE ONLY Affairs Apphcat ecepted by Data Area Ph or Grout Inspection by Date— 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 CK INFO CASH RECEIVED BY DATE PERMIT NO 124 inEv I" �m