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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC IIEALTH SERVICES ,�U 11J �!�� ENVIRONMENTAL HEALTH DIVISION yyI 1601 E. HAZELTON AVE. . PIiONE (209)468-3'I20;_ '•i t!{r; i. I;;L a i' + T P O BOX 2009, STOCKTON, CA 95201 P. PERUIT EXPIRES 1 YEAR FR06i 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 in compliance with San Joaquin County Ordinance No. 5119 and 1062 and the Rules and Regulatione of San Joaquin County Public health Services. Job Address 13170 Grant Line Road/205 Sr Byron Rd. City Tracy Lot Size/Acreage 62 Owners Name Dividend Development Address 2300 Danville Boulevard Phone 415/256-7300 Contractor Spectrum Address2825 E. Myrtle Dr_, StantLq€Im,,eNo. 512268 Phone 209/465-8712 TYPE OF WELL/PUMP: NEW WELL IA WELL REPLACEMENT 1-1 DESTRUCTION LI Out of Service Nell CI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well Yq 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 [1 Industrial U Open Bottom /O Manteca Die, of Well Excavation Dia. of Well Casing 2" C.] Domestic/Private R Gravel Pack V Tracy Type of Casing PVC Specifications Sch 40 .0010 10 I'I Public f:l Other f'1 Delta Depth of Grout Seal 5' Type of Grout Bentonite/Ce en I I Irrigation - T Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter 21' Sealing Material & D pth S' Depth 25' Filler Material & Depth 25' IYPE OF SEPTIC WORK: NLW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I 1 INo septic system permitted it public suwor is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of toll to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of tines Total longth/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS If Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 hereby cartify that 1 have prepared this application and that the work will be done in accordanco with San Joaquin county ordinances, state laws, and rules and reputations 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust c I f all required inspections. Complete drawing on reverse side, p Signed X Title: R D MENT USE ONLY Application Accepted by �j Data Pit or Grout Inspection by Da �I-// Final Inspection by ' Date Additional Comments: Applicant - Return all cop ied"to: San Joaquin County Public health Services, Environmental Health Permit/Services 1601 E. Ilatelton Ave., P 0 Dox 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMiIJTTED /JC/nail RECEIVED BY / DATE` PERMIT*NO. EH 13-21 t11EV.ria sr go — (// ;/ 5Z ( ( -�S�3 EH t�.2a (�//�