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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE {209}468-3420 P 0 BOX 2009, STOCKTON, CA 95201 KI JOB 420-3710-01 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) Application in hereby made to Ban Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with Sen. Joaquin County Ordinance No. 549 and 3.952 and the Rules and Regulations of San Joaquin County Publ c Healt"e� APN 244-04-11 D t*it-,�vEs� {� Job Address y y City y Cambridge Plaee & Sycamore Parkwa Trac Lot Size/Acreage _ __. Kul Sharma,Acting Dir. /W Owner's Name City of `Tr.;acy Address 325 East 10th St. ,Tracy,Ca. _ _ Phone 835-2211 Contractor Spectrum/Kleinfelder Address 2825 E. Myrtle St. License N0.512268 Phone94-1345 i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRW!FI =21MF-1Ei PUMP INSTALLATION © SYSTEM REPAIR 0 OTHER 0 Monitoring Well O (� 4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. R 4;" 2 test b( rrnE FOUNDATION AGRICULTURE WELL OTHER WELL ftTSiSidhWS 6" diam INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 10' Deep C1 Industrial .0 Open Bottom C1Manteca Dia. of Well Excavations NO GW 1.1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Spstifisatioas anticipated. I�- I') Public Cl other n Delta Depth of Grout Seal GW encounter d(� I I Irrigation —.Approx. Depth t I Eastern Surface Seal installed by will backfill wit h Repair Work Done 0 T p hole plug' p Type of Pum H.P. State Work Done_ Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION ! I DESTRUCTION l I (No septic system permitted if public sewer is �. available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms f Character of soil to aI depth of 3 feet: Water table depth j SEPTIC TANK. O Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS 11 Depth Size Number �- SUMPS L1 Distance to nearest: Well Foundation Property Line j DISPOSAL PONDS ❑ I hereby candy 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 foIlowi "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 Calif �• The applicant s al or al requi i ns. Complete drawing on reverse side. Signed 'E' Title: _ Senior Engineer pate; April 16, 1993. F R PARTMENT USE ONLY Application Accepted by Data Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE) INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT'N0. i EH 14-MiRtcV:t ice 41 S� 'i/ l��2/5� XO 71 '