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aDPLIC,TTnN • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 (Complete in Tripiicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application 18 made in compliance with San Joaquin County Ordinance No. 749 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 27337 So. Banta Rd, Robertson and Sons City Tracy Lot Size/Acreage 174.32 acres Owners Name Stanley Robertson Address 8063 West Grantline Rd, Tracy Phone 835—1251 Contractor FugroGeosciences Address6105 Rookin, Houston. TX License No-q57556015 Phone(71 8 55 0 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C CPT OTHER M Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -: Inousinai O Open Bottom a Manteca Dia. of Well Excavation In Dia. of Well Casing none : Oomes ic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_none Specnlcations- i'I Puhljc ❑ Other f7 Delta Depth of Grout Seal Max 150 ft Type of GroutNeat Cement rout i I...Uation _Approx. Depth I I Eastern Surface Seal Installed by FueroGeosciences Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will "me: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Character of wit 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 C1 No. 8 Length of lines Total length/size FILTER BED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby candy 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 comfy 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. I Contractors hiring or rub-contracting signature certifies the following: "I comfy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compen". non laws of California." The spots tit ust I recur ad inspections. Complete drawing on rover" side. J�1tn /1 n Signedx Title: Hydrogeologist Date: FOR DEPARTMENT USE ONLY 'Q /y+- I�Lr.2 Application Accepted by , ' ` Oats 4 y' ` Area 1 J Pit or Grout Inspection by ) Date Final Inspection by_ Date AdditionalComments: �f � 'uv(,� jilt —.Ltriti� J .applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services pL�li 445 N San Joaquin, P O Boz 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT flEMITTED CASH RECEIVED BY D.A�TE q PERMI�T7N+�0. En 13.74111EV irnll ", 1001 ( q-