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APPLICATION } SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. i ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM—DATE -ISSUED i (Complete in Triplicate) . Application is hereby made to San Joaquin County foie a permit to construct and/or install the work herein described. This application is made in coVilance vith San Joaquin County Ordinance No. 5k9 -and 1862 and the Rules and Regulations of San ' Joaquin County Public Health Services. I Job Address 2880 MANCUSO ED . Ciry TRACY Lot Size/Acreage Owner's Name pOMRfI RFAI_ ESIATE_ Addre�s P _0_ BO 805 TRACY — Phone 835— �j !4. Contractor KENNINGS BROS., DRILLAddress 3525 PELANDALE AVE. License No. 290813 Phone 545- 1185 TYPE OF WELL/PUMP: NEW WELL XIX - � WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well L� PUMP INSTALLATION U SYSTEM REPAIR Cl OTHER (3Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 100 r SEWER LINESt__ DISPOSAL FLD. PROP. LINE k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom 0 Manteca I Dia. of Well Excavation I Dia. of Well Casing 6 n r xxo0m, esticIPrivate tX Gravel Pack X_XTracy Type of Casing_ PVC Specifications N Il Public ! Cl Other f n Delta € Depth of Grout Seal t Type of GroutE�N d N &i NG s I 1 Irrigation ;? +` _ Approx. Depth I L Eastem Surface Seel Installed b �. r Repair Work Done' L3 Type of Pump H.P. State Work DoneIT Well Destruction O Well Diameter _ Baling Material A Depth ` Depth1 � Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR 1ADDITION 1 I DESTRUCTION 111No septic system permitted if public sewer is ± I� available within 200 feet.l installation will serve: Residence Commercial— Other t Number of living units: Number of bedrooms J Chsractar of soil to a depth of 3 feet:- Water table depth G SEPTIC TANK © Type/Mfg 1Capacity. No. Compartments PKG. TREATMENT PLT. ❑ Method of Dlspos O Distance to nearest:s �W 1j P�D�y_4i 1 .1 + 1 TH JIfKVi IS LEACHING LINE' C-1 No. 8 Length of lines �l Total lelottyflio a FILTER BED t ll Distance V;nearest: Welt q .� rty Line �h ) SEEPAGE PITS 11 Depth Size Iw Number SUMPS , �'. `•`.'.I_I Distance'to nearest: Well €� Foundation Property Line DISPOSAL PONDS D A 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 h ruNs 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 lssued l shall arnploy persons subject to workman's compensa- tion taws.of California."- The applic'an't must call for all required inspeetlons. Complete pdrowinq on reverse side. Signed X t ,.Q.m�� D i } '� ,7ilia: rte" Date: FOR.DEPA MENT USE ONLY W Application Accepted by - i Date — Z Area a Pit or(;rout Impaction byDatef Final Inspection by Date �� ^IZ Additional Comments: ref/ - e rales �e 4e! d �-�rCe�- et sl ewo� Irak f du-e- Applicant - Return all Capes to: San Soaquin Dunt' Pub) c ea ervices lth Permit/Services Bavlronment:al He's qr rel` wa 445 N San 'Joaquin, P O.8otr 2009, Stkn, CA 952D1 INFAMOUNT DUE] AMOUNt REMITTED CASH RECEIVED 9Y DATE' PEflMIi'N0. fk 114-2111Em 13-24 IIIEtr.t i n al w1Y tO� �' '� I 13y, i