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* SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ! P O SOX 2009, STOCKTON, CA 95201 1 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;I (Complete in Triplicate) Applicnt on ie heby to San or �ounty 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. San Joaquin County SouthgaS corner of I-5 and Hwy 120 Lathrop60 + acres Job Address near Lat rop; bpN 241_non-11 _ CityLot Size/Acreage 3825 Hopyard Road, #214 Kearney Ventures, Ltd: Address Pleasanton, CA 94588 Phone(510)847 8910 Owner's Name Earth Systems Consultants; Inc. 4378 Santa Fe Road Contractor Pacific Geoscience Div.'s Address San Luis Obispo, CA 93401 License No. 606513 Phone 805 544=5187 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 5 DESTRUCTION Ci Out of Service Well ❑ i Well PUMP INSTALLATION E3 SYSTEM REPAIR ❑ OTHER ❑ Monitor X DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R inch. Dia. of Well Casing inchO X)KDomestic/Private X11 Gravel Pack ❑ Tracy Type of Casing_ PVC Specifications See attarharl ' I'I Publici I n Delta Depth of Grout Seal Approx. 10' Type of Grout�Pntonite Pell-e S I I Irrigation prax. Depth I I Eastern Surface Seal Installed bye 0 e wd er e . Repair Work Done ❑ Type of Pump 1 H.P. Slate Work Done _ Well Destruction ❑ Well Diameter 1 Sealing Material & Depth r� Depth 1 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i i lNo septic system permitted it public sewer is I I available within 200 feet.l c v� Installation will serve: Residence_i :Commercial_ Other Number of living units: Number!of bedrooms Character of soil to a depth of 3 feet: �° Water table depth Q SEPTIC TANK ❑ Type/Mfg Capacity No O�f-d' PKG. TREATMENT PLT. ❑ Mer- 193 r Distance to nearest: Well Foundation Property 1 LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to.nearest: Well Foundation Property Line i NTAL HEALTH SEEPAGE PITS 11 Depth Size Number EEWITISE RVIUhZi 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 iCounty 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 workmen'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, I shall employ persons subject to workman's compensa- tion laws of C r 'a." j The ap.Iic ryt�s call fora req r d ti a. Complete drawing on reverse side. Signed X / r Title: Civil Engineer Date: FO DEP RTMENT USE ONLY Application Accepted by LDate Area Pit or Grout Inspection by Date Final inspection b Date Additional Comments: ' a�S q Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services g 445 N San Joaquin, P Box 40-4, 2009, Stkn, CA 95201 A ,,,FV FEE AMOUNT DUEAMOUNT REMITTED " CASH RECEIVED 8Y DATE PERMIT"NO. /INFO n EK 13.74 tREV.t,n 51 W if vC�3 3 EK lhaa -• - �:a.. w ti