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fII. • APPLICATION FOR PERNI� capySAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 County Public Health Services. Job Address 1050 r antline Road City Tracy Lot Size/Acreage 14.41 Acres _ Owner's Name Mark III Engineering Address 5101 Florin-Perkins Rd, Sacto Phone (916)451-9213 Services Contractor Soil Exploration Address P.O. Box 5993, Vacavill%ense No. 582696 Phone(707)451-921 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION Ll Out of Service Well ❑ (Hydropunch) PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES 75 ft DISPOSAL FLD. NA PROP. LINE 10 ft (feet) FOUNDATION 45 ft AGRICULTURE WELL 500+ OTHER WELL 700+ PITS/SUMPS25 ft INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation maX Dia. of Well Casing NA 6tl Bemesfic/Private ❑ Gravel Pack 18 Tracy Type of Casing_ NA Specifications NA I Public IN Other Hydropundh Delta Depth of Grout Seal 12-15 ft Type of Grout cement I I Irrigation ld'.Approx. Depth 1 I Eastern Surface Seal Installed by to be installed by Contractor Repair Work Done ❑ 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 (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence _ Commercial _ Other _ Number of living unite: Number of bedrooms ° Character of toll to a depth of 3 leer: ;'Arffgr table depth SEPTIC TANK ❑ Type/Mfg Capacity * ,No,.lCompartments PKG. TREATMENT PLT. ❑ '`• I '� Method of Disposal Distance to nearest: Well Foundation —^sem—rr=4E2 efAbe2M`Line.{ = 4 t LEACHING LINE ❑ No. R Length of linea 'l iT'dt6j lfttgth/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub contracting 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 laws of Calilornie." Theeppficant st cal lull e uired Inspections. Complete drawing on reverse side. Signed X Title: � / Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant — Return all copies to: Sen Joaquin County public Health O� Services, Environmental Health Permit/Service, r� 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 /V�)1/►1//. FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. CK If INFO EH ;3 24 IREV.,re Si EH 420 .t.. F