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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION r P O BOX 2009, STOCSTON, CA 95201N �g � i (209) 468-3447 }4 PERMIT EXP_I_RES ,1,__YEAR PROAL DATE ISSUSD ENVIRONMW, 'FI,�E.HEQ'l;TH (Complete in Triplicate) PERM?TISEWIM 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 27383 South MacArthur Road f City_Tracy Lot size/Acreage C 1 Acre I Homestead ' ' Owner's Name Land Development EOrp. Address P.O. Box 960, Millbrae, CA Phone (415) 692-1432 y t + Contractor B'& .FDrilling Co. Inddfe$0663_CE66_ Circle.,(95.742).�ticense No. 5-19428 Phone(916)63.1.=954 :' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service tfell 0 . + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER iZ(( Monitoring Well ❑ r DISTANCE TO NEAREST: SEPTIC TANK _ 2t 50Ft. SEWER LINES 50Ft. DISPOSAL FLD. 350FtpRO borings) FOUNDATION < IOFt. AGRICULTURE WELL 50FtOTHER WELL 50FtQITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r f� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing N/A M Domestic Aisrrva e ❑ G(ave! Pack 0 Tracy(south)Type of Casing N Specifications N/A M Public ER Otherborings ❑ Delta Depth of Grout Seal to Surface Type of G rout c ement A ent ori t e I CJ Irrigation 3� ApproO Depth ❑ Eastern Surface Seal Instailed by B &- `�Di i7 7 in Co. Inc. Repair Work Done C] T p Type of Pum H,P. State Work pone _ ' Welt Destruction 1) Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION G INo septic system permitted if public sewer is available within 200 lest.) v { Installation will serve: Residence Commercial— Other N/A ul Number of living units: Number of bedrooms Character of Boll to a depth of 3 foot 1 Water table depth l�1 SEPTIC TANK ❑ Type/Mfg': Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line I ; LEACHING LINE D No. & Length of lines N/A Total length/size FILTER BED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth 191A= Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line p DISPOSAL PONDS p ` 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 Home owner or licensed agent's signature cenifies 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 laws of California." Contractor's hiring or sub-contracting signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• tlon laws of California." The applica W, ust tail for re ad inspections. Complete drawing on reverse side. Signe itle: __Regional Manager/Engineering Date: _ 6/7/91 aures F. Frumm, R.G. FOR D61 EPARTMENT USE ONLY Application Accepted by Date �L 1 ` 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 DIVISION PERMIT/SERVICES- t 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA' 95201FFE INFO AMOUNT DUE �-J Ay10UNT REMITTED tK RECEIVED BY DATE PERMI7'NO. �+ CASH + EH 1241REV,c/Mal Est 74.4•Ie L ,