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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 I YEAR ROM DATE ISSUED (Complete in Triplicate) Application Is hereby made.to San Joaquin County for a permit to co Strutt and/or install the work herein described. This application Is made in compliance vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 16555 West Von Sosten Road (it, Trac Lot Size/Acreage 2.5 Acre i Owner's Name Li3mmersville School Address 16555 West Von Sosten Road Phone(209) 835-0138 j Groundwater Techlloltx dress est ar a ento, tAS4451140 C57434343 Contractor (916) 372-47 0 License t+fo. Phone TYPE OF WELL/PUMP: NEW WELL C3 WELL REPLACE AENT ❑ DESTRUCTION ❑ Out of service Well ❑ ! PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST; SEPTIC TANK :100fr iSEWER LINES DISPOSAL FLD.-90OYdSPROP. LINE 51 L(' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ci Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 inch C7 Domestic/Private ❑ Gravel Pack 6 Tracy Type of Casing PVC Specifications SCh 40 I'I Public Cl Other n Delta Depth of Grout Seal 2-3 feet Type of GroutC�t GTOUt I I Irrigation `Approx. Depth 1 I Eastern Surface Seal Installed by Groodwater T 1- c + Repair Work Done U Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Z Depth Bentonite 3-4 feet Depth Piller Material a Depth #2 Sand 3-20 feet TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADOtT10N i I DESTRUCTION 1 1 INo septic system permitted if public sewer is ! available within 200 feet.) Installation will serve: Residence` Commercial— Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, E7 Method of Disposal Distance to nearest: Well Foundatio Property Line LEACHING LINE El No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundatio Property Line SEEPAGE PITS l I Depth Size Number SUMPS LI Distance to nearest: Well Foundatio Property Line DISPOSAL PONDS 0 , 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 k rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "i certify that in the performance at 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 the following:"I certify that in the performance of the work for which this per nit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant m call for all r jdirr s omplete drawing on reverse si e. I Signed X / Date: Title: ep i FOR DEPARTMENT USE ONLY Application Accepted by Date r� f'� Area Z13c) Pit or Grout Inspection by /' Date , Final Inspection by Date Additional Comments Applicant - Return all copies to: San Joaquin County Public lealth Services Environmental Health Perini /Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE I 7 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. EH 13-24• tREV.iiMsI EH 14.26