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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE � '�)jRjj ENVIRONMENTAL HEALTH DIVISION �•I �Z(( 445 N SAN JOAQUIN, PHONE (209)468-3420 G P O BOX 2009, STOCKTON, CA 95201 JUN 14 1994 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEUVv��N (Complete in Triplicate) PERMIA4ENTALHEALTH Application in hereby made to San Joaquin County for a permit to construct and/or install the work hereljnV� lbed. This application is awde in compliance with San Joaquin County Ordinance No. 51+9 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 _ PACIFIC RIM ENV Address PO BOX 80427 BAKERSFIHki,'9WP,, 649163 Phone 805/326-017 Contractor ------- TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR D OTHER O 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 1 ) Industrial FJ Open Bottom L1 Manteca Dia. of Well Excavation—�n Dia. of Well Casing 411 (I Domestic/Private Ll Gravel Pack [X Tracy Type of Casing- PVC Screen Specifications I'I Public 1 1 Other (-I Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 1-7 Type of Pump N/A H.P. State Work Done — Well Destruction O Well Diameter Sealing Material b Depth—_ — Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION I I (No 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 ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size- FILTER BED [J Distance to nearest: Well Founoatron Property Line SEEPAGE PITS 11 Depth Size __ N fA_ _ Number - SUMPS L I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be clone 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 laves of California."' Contractor's hiring or subcontracting 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." The applicant must 1�r all r quired inspsetions. Complete drawing onreverse side. Signed _ - �—� Title: � ( -GC Date: s � FOR DEPARTMENT USE ONLY Application Accepted by — Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Appli.•ant - 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 CK CASH RECEIVED BY DATE PERMIT NO. Page 13A EH132trnEv rinsr ,., EH 14.2111 •-- -- — ----