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��. APPLICATION SAN . JAQUIN COUNTY PUBLIC HEALTH .,SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC TON, 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 1562 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 16555 West Von Sosten Road City Tracy l,ot Size/Acreage 2.5 . Owner's Name,Lammersville School Address 16555 West Von SOsten Road Phone (209) 835-0138 V hR -P-31- 14Q1 Halvarc I Drive Contractor Grouridwatk)r TechnOlOcd�dressSuite 140r W. S �nto�itenseNo,rCA 95691 91 �d �Phone(916) 372-4700 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT M DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L-I OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �1 OOft SEWER LINES 71 OOft DISPOSAL FLD. 50Oyd:FPROP. LINE 50ft t{} L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-] industrial ❑ Open Bottom ❑ Manteca Dia. of Will Excavation OtintlDia. of Well Casing 2inch EI Domestic/Private Cl Gravel Pack E;Tracy Type of Casing— PVC Specifications SChl) f'3 Public 1-1 Other n Delta Depth of Gtout Seal 2-3ft Type of Grout ?t Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Groundwater Technology, Inc. Repair Work Done U Type of Pump H,P. Stto Work Doe Well Destruction ❑ Well Diameter Sealing Material & Depth 1�entn onite ,3— ee Depth Filler Material 16 Depth #2 Sand 3-20feet TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITION I I DESTRUCTION i I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Ca city No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest. Well Founda ion Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Founda ion Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be doe 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 he 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this rermit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m or a0equ. ns omplate drawing on reverse side. Signed t Titie: n �� may!/ Date: FOR DEPARTMENT USE ONLY �} L� Application Accepted by Date �S `r: _ Area Pit or Grout Inspection by Date / O{ I 2- Fin I 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 0 $ x 2009, Stkn, CA 95201 �01O-D FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DAATE�j PERM/IIT''tNO. . EN t3-24 IREV.I/P1 sl 0""� ��+. /rl ' j i✓ /� g�^IJCJ�p3 �� EN 14.28