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• '�` ApPi•ICATTON �� ,i SAN JOAQUIN COUNTY PUBLIC HEALTH SLVAECEIVED ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 0 C T 2 3 1892 P 0 BOX 2009, STOCKTON, CA 9520NVIRoNMENTAL HEALTH PERMIT EgPIRES ;1 YEAR FROM DATE ISSUERMIT/Se"VIVIO (Complete in Triplicate) Application in hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is rade 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 SAVANNA & BLUEGRASS LANE City TRACY Lot Size/Acreage HARVEST GLEN VENTURE 1 7,07 BROADWAY, STE. 1600 (619) -699-8294 Owner's Name Address Phone 'Contractor WEST HAZMAT• Address 3233 FITZGERALD License No.554979 Phone916 638— M TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION [)0 Out of Service well ❑ PUMP INSTALLATION ❑ 11 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOiFAMOtN4. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ..� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATINS u 0 Industrial !�❑ Open Bottom ❑ Manteca M Dia. of Well Excavation ItDia. of Well Casing 4 ❑ Domestic/Private ❑ Gravel Pack R3 Tracy ? type of Casing_ DVC _ Specifications I'I Public Ell Other n Delta Depth of Grout Seal 57-6 �' �; Type of Grout RWONTIL I 1 lrrigation _Approx. Depth l I Eastern. Surface Soul Installed by + CEMENT Repair Work Done U Type of Pump H.P. State-.Work Done Well Destruction IN Well Diameter Orr Sealing Material to Depth BENTORITE CEMENT 57-62' Depth ^ 57-62' ____ F111er Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I l (No septic system permitted it public sewer is �i available within 200 leet.l Installation will serve: Residence_ Commercial Other Number of living units:' L : Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Companments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line p LEACHING LINE Cl No. & Length of lines Total length/site FILTER BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 1' „ 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 workmaA'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,l shall employ persons subject to workman's compensa•r. tion laws of California." ii The ap can st call for all gquired inspe bona. Complete drawing on reverse side, Signed — Title: CONSTRUCTION SERVICES SR. Data:IRSPECTOR lf]-22-42 FOR DEPARTMENT USE ONLY f�-� Application Accepted by ' r Date�ZQ— Area Pit or Grout Inspection by Date ' Final Inspection by Date Additional Comments, Applicant — Return all copies to: an Joaquin Court y Public Health Services ef0 Environmental',Health Permit/Services g / 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE �! INFO CK AMOUNTD,UUEE AMOUNT REMITTED.' „ CASH RECEIVED BY DATE tPEMT*NO. ENc744 IREV,v/nalEM 11.2E