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APPLICATION FOR PERMIT u SAN JOAQUIN COUNTY PUBLIC IIEALTIi SERVICES' ENVIRONMENTAL ILEALTH DIVISION O 1601 E. HAZELTON AVE. , PHONE (209)468-3420==* O P O BOX 2009, STOCKTON, CA 95201 ,U IN 1 3 PERMIT EXPIRES 1 YEAR FROM DATE ISS�kb';RONMEN ,"X HEALTH (Complete in Triplicate) p�RM'T/SLEV+GES Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made In compliance vith San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public health Services. Job Address 13170 Grant Line Road/205 & Byron Rd. City Tracy Lot Size/Acreage 62 Owner's Name Dividend Development Address 2300 Danville Boulevard Phone 415/256-7300 Contractor Layne Environmental Address 4300 Evora Rd., PittsburSknse No. C57600469 Phone 415/682-556 TYPE OF WELL/PUMP: NEW WELL 09 WELL fICVLACEMFNT ll DESTRUCTION Cl Out of- Service Well El PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ 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 0 Industrial U Open Bottom ❑ Manteca Die. of Wall Excavation Dia. of Well Casing 2" f.l Domestic/Private §� Gravel Pack X1 Tracy Type of Casing_ PVC Specifications SCh 40 .0010 lot I'1 Public I:1 Other f'1 Delta Depth of Grout Seal 51 Type of Grout Bentonite/Cement I I Irrigation —Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter 201 Sealing Material b D pth 5, Depth 25' Filler Material b Depth 25' 1 YPE OF SEPTIC WOI1K: NEW INSTALLATION 1 I IIEPAIR/ADDITION 1 I DESTRUCTION I 1 INo sepllc system permmed if public suwar 1s available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of colt to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No, b Length of lines Total longth/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordanco 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, 1 shall riot employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cenifies 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 mt ca I f all�uirodinspections. Complete drawing on reverse side. Signed X TitlS"(--,(� �� P1�71 '11�� 1 1 uY�`�?(� ate: [ Q'�' ENT USE ONLY Application Accepted by Date ` A Pit or Grout Inspection b 3 �y Pe Y Date �q / Final spaction by Date Additional Comments: 17, Sl / Applicant – Return all copies to: San Joaquin County Public Ilealth Services, Environmental Ilealth Permit/Services 1601 E. Ilazelton Ave.. P 0 Dox 2009. Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITT/E]Dr) ^/C K RECEIVED BY PATE PERMIT'NO. • EH 1721(REV.rin51 ."v GIS 8 `71 151z— Erf 14-I0 l