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SAN""J'6AQUIN COUNTY PUBLIC HEALTH . RVICES 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 In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. l tf ✓ i Job Addressl 7750 WFTyv A Cityea eekten Lot Size/Acreage Owner's Name SMS Briners Address 1 7750 E. Hwy 4 Phone 941 =851 5 Contractor Purvianee DrillersAdtl7RG' POBox 64 ,Linden License No. 377923 Phone 8873554 TYPE OF WELL/PUMP: NEW WELL = WELL REPLACEMENT n DESTRUCTIONOut of Service Well ❑ 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 Cl Industrial ❑ Open Bottom C: Manteca Dia. of Well Excavation 1 5 Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack C Tracy Type of Casing_ Sch 80 PVC Specifications F_dRn i'I Public 1-1 Other f Delta Depth of Grout Seal 135 Type of Grout concrete I I Irrigation 2_0APProx. Depth I � Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump sub H.P. 1 State Work DonQVerbore exsisting mc nt. Well Destruction ❑ Well Diameter Sealing Material It Depth Wpl l 19" axnavati an--complete to Depth Filler Material a Depth 200 r 6rr monitoring Well. TYPE OF SEPTIC WORK: NEW INSTALLATION ! REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) Installation will some: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Character of and to a depth of 3 feet: Water table depth (j .SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal Lti Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line G SEEPAGE PITS It Depth Size Number C SUMPS LI Distance to nearest: Well Foundation Property Line (� DISPOSAL PONDS ❑ rj I hereby comity that 1 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: "1 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 workmen's compensation laws of California." Contractor's hiring or 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 Iowa of California." 1F The a plicant m t call for all e u inspections. Complete drawing on rev se side. (� O Q Signed �� L'�G'Z�-+a-« Title: QDate: Q- 7 -/3 FOR DEPARTMENT USE ONLY Q -7 Application Accepted DV `` p Date ` Pit or Grout Inspection y Date o 37� inat IIn�Tspect//ion byp'/ Date Additional Comments: W (D r/ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stk., CA 95201FEE I !! INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO, Ea-2x IPEV.iinS� EHH I ]e Rid &0t6=y 3