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{ <br /> APPLICATION FOR PERMIT <br /> SAN .IOAQ'CIIN COUNTY PUBLIC IIEALTIi SERVICES <br /> I ENVIRONMENTAL aEALTU DIVISION J U i .3 1991 <br /> 1601 E. HAZELTON AVE. , PRONE (209)468-3420; yl(ji()NME�NITAL HEALTH, <br /> P O BOX 2009, STOCKTON., CA 95201 C <br /> P-MIT- EXPIRES 1.YEAR FRAM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application iri hereby made to SanJoaquinCounty for a permit to construct and/or install the work herein described. This <br /> application is made in compliancewith Ban Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Ilealth Services. <br /> Job Address 13170 Grant LineRoad/205 & Byron Rd. City Tracy Lot Size/Acreage 62 <br /> Owner's Name Dividend Development Address 2300 Danville_Boulevard phone 415/256--7300 <br /> Contractor ^ Spectrum Address 2825 E. Myrtle Dr., StantpAmse No, 512268 Phone 2_09/465-8712 <br /> TYPE OF WELL/PUMP: NEW WELL A WELL REI'LACEMF.NT 11 DESTRUCTION Ll Out of Service We11 Li <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER Ci Monitoring Well Y-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1.1 Industrial U Open Bottom ❑ Mantoca Die, of Well Excavation B.. pia. of Well Casino 2+r <br /> 1'.l Domestic/Private 12 Gravel Pack $_1 Tracy Type of Casing PVC Specifications SCh 40 .0010 blot <br /> I'1 Public I'1 Other i 11 Delta Depth of Grout Seal 51 Type of Grout Bentonite/Cement <br /> t <br /> 114611ation _.Approx.. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done <br /> Well Destruction 0 Well Diameter: 2" Scaling Material 6 A pth 5 <br /> Depth 2'Sr Filler Material & Depth 25* VJ <br /> 1 YPL OF SEPTIC W0RK: NEW INSTALLATION I I IIEPAIRIADDI'EION I I DESTRUCTION I I INo septic system potmille:d if public sower is <br /> available within 200 feet.1 G <br /> Installation will serve. Residence^' Commercial____ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 foot: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to I nearest: Weil Foundation Property Line <br /> LEACHING LINE L"1 No. & Lc4h of lines Total fongth/sire <br /> FILTER OED 1=1 Distance to nearest: Well foundation Property Line <br /> SEEPAGE PITS 1 I. Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS a { <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> ruses and regulations of the San Joaquin f County <br /> 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, t shall clot <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub•conlraciing signature <br /> 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 componsa- <br /> tion laws of California." <br /> The applicant ust c I f all required inspections. Corpploto drawing on reverse side. <br /> Signed Title: -e tT12n C� Date: <br /> ENT <br /> R D WENT USE ONLY I <br /> Application Accepted by Date <br /> Pit or Grout Inspection by e5rDa ! Final Inspection by W <br /> para <br /> Additional Comments: <br /> Applicant - Return all copies to: .San Joaquin County Public health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIT71 p CK RECEIVEDATE PERMIT'N0. <br /> INFO CASH ED D BBY Y <br /> . Err I3-21IAEV.tin srz�/�/ ®/ /57 2 <br /> f/l 14-26 1 !!!/// (/ C/ ((/ J <br />