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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH'SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 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 15 EAST GRANT LINE RD city TRACY Lot Size/Acreage Owner's Name THE CUSTOMER COMPANY Address PO BOX 886 BENICIA CA 94510 Phone 707/746-0120 Contractor 0 — Contractor PACIFIC RIM ENV Address PO BOX 80427 BAKERSFIELQic,M�W, 649163 Phone 805/326-017 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION O Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O Monitoring Well IN 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 Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 411 Ci Domestic/Private O Gravel Pack DO Tracy Type of Casing PVC Screen Specifications I'l Public FI Other n Delta Depth of Grout Seal Typo of Grout I I Irrigation —Approx. DeVA I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump IV// H.P. _ State Work Done _ Well Destruction 0 Well Diameter Sealing Material i 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 it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other Number of living units: Number of bedrooms N/A Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & 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 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 workmen'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 issued, I shall employ persons subject to workman's compensa- tion laws of California' 9 The applicant mus f �alluired inspections. Complete drawing on reverse side. Signed 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: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE t1INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED By DATE PERMIT'NO. PQgB I3C • EM I�IREV.1 i n sl EH 1146