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APPLICATION. PPLIGAION. FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ONS ENVIRONMENTAL HEALTH DIVISION to P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 �T,,L,m 1cYDTR�� YEAR FROM DATE ISSUE (Complete in Triplicate) work Thi pplicstion is heb made,to San Joaquinwith Cc`unt lnoCoun Ordlnanceconstruct and/or uinstall e No. 549and1862and the Rules and Regulationsds mad in nce of San ipplicstioa Joaquin County Public Health Services. S. of Trac LLNL Site 300, Corral Hollow Road Sy Lot Size/Acreage _-..._.._.. /job Address City U.S. Dept. of Energy Address 1301 Clay Street, Oakland, CA Phone (510) 273-711 (916) Owner's Name 1780 Vernon St. 783-9733 CA 95678 265556 phone PC Exploration Address Roseville, License No. Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ TYPE OF WELL/PUMP. NEW WELL O OTHER N Monitoring Well pft� PUMP INSTALLATION ❑ SYSTEM REPAIR Cl PROP, LINEatory boreFio es SEWER LINES —.------�- DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL _ PITS/SUMPS _ FOUNDATION AGRICULTURE WELL _ WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,r INTENDED USE TYPE OF W .—_---- --------'-- Dia. of Well Casing O Open Bottom ❑ Manteca Dia. of Well Excavation ite [l Industrial pVC Specifications ❑ Tracy Type of Casing U Domestic/Private ❑ Gravel Pack Variable Type of Grout 1-1 Other ❑ Delta Depth of Grout Seal ,___----- M Public PC Ex loration cl IrnUation .— Approx. Depth ❑ Eastern Surface Saul Installed tate Work Done _ H.P. (` Repair Work Done U Type of Pump Sealing Material i Depth Well Destruction ❑ Well Diameter Filler Material L Depth Depthsysr TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Tl DESTRUCTION CI (No septic 200 feet.) if public sewer is Installation will serve: Residence Commercial_. Other__ -- Number of living units: Number of bedrooms` — — _—Watel •,h I Character of soil to a depth of 3 feet: + ' Pa►�R'!dAp _ Capacity_—_ ;. SEPTIC TANK ❑ Type/Mfg �3 9, f bisposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well _._.._— Foundation.. — Props rty Line — — Total length/size, 1 LEACHING LINE ❑ No. b Length o1 lines _ Property Line .ti - ,_— FILTER BED [:I Distance to nearest: Well Foundation _ - V, Size — Number SEEPAGE PITS 11 Depth Property Line - SUMPS LI Distance to nearest: Well Foundation_— DISPOSAL PONDS ❑ rk will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this application and that the wo rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I cartity that in the performance of the work for which this permit .s issued, 1 she net 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 permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. t �cy/9Y �� %TTST77 X : �� Title: erection Lamer _ Date: Signed FOR DEPARTMENT USE ONLY Application Accepted by Dated Area — Date Pit or Grout Inspection by --- Date Final Inspection by Additional Comments: Applicant - Return all copies to: SAN JUAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 CK —'RECEIVED By DATE PERMIT NO. FEE AMOUNT DUE - AMOUNT REMITTED CASH INFO -- �' EH 13.24 IREV.I/M 5) Ear—26 �� _