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APPLICATION 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 Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 15 EAST GRANT LINE RD city TRACY Lot Size/Acreage Owner's Name THE CUSTOMER COMPANY Address PO BOX 886 BENICIA CA 94510 Phone707/746-0120 Contractor PACIFIC RIM ENV Address PO BOX 80427 BAKERSFIELDL;$!99fio, 649163 phone 805/326-0173 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR Ll OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 411 1] Domestic/Private ❑ Gravel Pack K1 Tracy Type of Casing PVC Screen Specifications I'l Public F1 Other 171 Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump N/A H.P. _--- State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material & 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.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms N/A Character of coil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. b Length of lines N/A — Total length/size -FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size N/A Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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." Contractor's hiring or sub-contracting signature certifies tho following: "I certify that in the porformance of the work for which this permit is issued, I shall employ persons cubject to workman's compensa- tion lowo of California." The applicant mus f all r uired inspections. Complete drawing on reverse side. Signed X Title: �Cfp� f /'/ �� Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inepoction by Date Final Inspection by Date Additional Commonts: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. D 3171 . EM 13-21(REV.I/n S) PQ,Se 1 EH 14.23 ✓✓