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.al'YLtl,�l1 lUIV SAN 9QUIN COUNTY PUBLIC dEALTH RVICES .ENVIRONMENTAL IIEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468"342Q-,,,- P 209)468=3420,-;P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE 13SUEII�j: �� (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 Countv Publth Servic �-�"-rem. Job Address 41-) eft. Diablo Ave. (Old Valley Pipeline ry Tracy Lot Size/Acreage Mile Post 215 Site Owner's Name N Jc J 61 Address F CPhone N �r c C2A ru;uA4 I �f�=� n- �� UBJ �-(P 2 2 Contractor � r Address �s$r=��^ a - ;9' }a L cense No. Phone TYPE OF WELL/PUMP NEW WELL A WELL REPLACEMENT i DESTRUCTION ❑ Out of Service Well. C PUMP INSTALLATION C SYSTEM REPAIR C OTHER ❑ Monitoring Well y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIrICATIONS Cl Industrial ❑ Open Bottom C Manteca Dia. of Well Excavation $ inc es Dia. of Well Casing 2 inches Gf Domestic/Private N Gravel Pack ki] Tracy Type of Casing__ SCh 40 PVC Specifications FI Public FI Other Delta Depth of Grout Seal 20 feet Type of Grout cement/bentc nite i i Irrigation _Approx. Depth I I Eastern Surface Seal Installed by V & W Drilling Repair Work Done L7 Type of Pump H.P. __ State Work Dns CA Well Destruction ❑ Well Diameter 2 inch Sealing Material i Depth cement naoni e grou Depth 40 feet Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I i REPAIR/ADDITION i i DESTRUCTION I i INo septic system permuted if public sewer rs j 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance witn San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 certity,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 must call for all required inspections. Complete drawing on reverse side. 1 C� c� Signed X r' Al w bell 0 bra Title: Date: 1 1 ` J F R DEP RTMENT USE ONLY Application Accepted byC Date � �l / Area 2� Pit or Grout Inspection by 297 Date / Final Inspection by Date Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services `2 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE CK INFO AMOUNT UE AMOUNT REMITTED CASH RECEIVED BY DATE o,023 f�PERMITT*N0. n�Re 13� EH • EH 1t�•M 7- (REV. INFO � � � A l � /_✓ �--- o,02 J7 1 l 2e