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i ` �►PL'�GATI� �-' ' t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONr1ENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, 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 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Grant Line Road right-of-way City Tracer Lot Size/Acreage Owner's Name City of Tracy Address 520 Tracy Blvd- Phone (20-) 47 Louise Street Contractor Precision Sampling AddressSan Rafael , CA 94901 License No. F JL3 2 Phone (A25) A56-9R17f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERM Monitoring Well ❑ 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 2-2 5 i nrh Dia. of Well Casind n Domestic/Private ❑ Gravel Pack OUracy Type of Casing PVC -RC14 10 Specifications I'I Public f=1 Other n Delta Depth of Grout Seal1;15`'Fe et Type of Grou g11- I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by __Parr;e;nn Sninpi ing, Ti C Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth �a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal rq Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 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 permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant m st call for requi d inspections. Complete drawing on reverse side. Refer to work plan (attached) for details Sig"ed X Title: _Project Engineer, Geomatrix Date: 9 zl �{ FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final InspectioZe 4nLD rX Additional Comments: (J� Or �► LApplicant - Return all copies to: San Joaquin County Public Health Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE FO AMOUNT DUE AMOUNT REMITTED CK �I'fN� nit RECEIVED BY DAT EN 1]•21 IREV.i i n 51 CASH E PERMIT'NO.�/�7 y'7 ��