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APPLICATION 2 RPM ago, SAN JOAQUII COUNTY PUBLIC HEALTH SERVI I ENVIRONMENTAL HEALTH DIVISION RECEIRU 445 N SAN JOAQUIN, PHONE (209)468-3420 0C.T 2 3 1992 P 0 BOX 2009, STOCKTON, CA 9520�NVIRONMENTAL. HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUEPERMIT/HAV1410 (Complete in Triplicate) 'r 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 County Public-Health Services. ?1-'3ss'' e Job Address SAVANNA & 1BLUEGkASS`TANE' City TRACY Lot Size/Acreage —57 :,t BROADWAY,`STE-"' 600 '' ' HARVEST GLEN VENTURE 1 707 Owner's Name Address Phone (6 '9 =699-8294 i Contractor WEST HAMATT l Address 3233 FITZGERALD License No.6S4979 Phone916 638-";: r: TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION [A Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 .. :_ �. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP0�1A'1 �.r PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL i�' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECI_FIC:ATIQNS Y Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation j Dia. of Well Casing 411 [.I Domestic/Private ❑ Gravel Pack Tracy Type of Casing___�](C i Specifications I'l Public ISI Other (-I Delta Depth of Grout Seal r17-0 ? Type of Grout—BENTONTTK- I I Irrigation `Approx. Depth I I Eastern Surface Soul Installed by `"� '� CEMENT Repair Work Done ❑ Type of Pump H.P. State'tWork Done , Well Destruction [ Wall Diameter ?__411 Sealing Material & pepth BE T0,WTTE,CEMENT , 7-021 r Depth ' Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other - Number of luring unuf:{ p 'Number.of�bedrooms ;R,�r-Y Character of soil•to,a.depth,of.3 feet: -y Water table depth SEPTI ` i �F f fth #. t7 i;.�r.yA p r4 r C TANK.. � ❑ T e/Mt k �:,:,'I. V.F:j"'v)J`:-•44.i�` w YP g Capacity- No. Compartments. PKG. TREATMENT PLT.❑ L. Method of Disposal I -iA,;7.Distance to nearest: Well Foundation Property Lirir3 ?t 2! LEACHING LINE ❑ No. & Length of linea Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth [ Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ` Y I 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 rules 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 she..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 P p +certifies the following: "I certify that in the performance of the work for which this ermit is issued, I shall em toy persona subject to workman's compensa-r f tion laws of California"' ? , The ap 'can at'call for all required ins pe'tions, Complete drawing on reverse side. Signed Tide: CONSTRUCTION SERVICES SR. Date: X0-22-92 ,rINSPrCTOR _ FOR DEPARTMENT USE ONLY Application Accepted by pate v Area (� " Pit or Grout Inspection by Date 14V/ Final Inspection by Date Additional Comments: m - ' r ifApplicant- Return all copies to: an Joaquin Coun y Public Health Services Environmental Health Permit/Services 4 s 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 / L FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PER INFO CASK . EH 13.21(REV.1 i It 5) �� EH 11.2E iif6