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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT Y 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED 22_S 0 � LC4 w (complete in Triplicate) 2-13- 070 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin I Local Health District. FGrant Line Road: West. of Paradise Road. 72 acres Job Address Parcel #237--300-1 and 213-070-43 city Tracy Lot Size 154 acres + PM 1 731-7 6r-c-,i4-14c- 835- -7114 Owner's Namerf Address _ Phone 1 2855 :Campus Drive, Suite 300.. Contractor Earth M_etriCS__InC. Address San Mateo, CA 94403 License No. Phone 415-578-990C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L1 SYSTEM REPAIR 11 OTHER iA sabsur/ace invest'— gation soil borin s M DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE None on site, N`AFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial N/A ❑ Open Bottom N/A ❑ Manteca Dia. of Well Excavation NIA Dia. of Well Casing NIA {�] ❑ Domestic/Private ❑ Gravel Pack IXTracy Type of Casing N/A Specifications 4v r'l Public fa Other f ❑ Delta Depth of Grout Seal N/A Type of Grout_.__N A _. I I Irrigation _..Approx. Depth I 1 Eastern Surface Seal Installed by N/A _ Q Repair Work Done ll Type of Pump H.P. State Work Done I Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') _ r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION [ I (No septic system permitted if public sewer is N/A a,�� Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms f'* �mL Character of soil to a depth of 3 feet: Aro3 table depth f I SEPTIC TANK LJType/Mfg Capacity— AI -11 Col nts ; I PKG. TREATMENT PLT. ❑ Method of Disposal I j j Distance to nearest: Well Foundation Property Line 1 1 ENV�I�IJ( NAE14 C� k LEACHING LINE N/A ❑ No. &,Length of lines Total lengt ze f FILTER BED ❑ Distance to nearest: Well Foundation Property Line r ]� i SEEPAGE PITS N/A I ] Depth I Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line „ DISPOSAL PONDS Q I 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 Local Health District. 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." } i ! The applicant must call for all required inspections. Complete drawing on reverse side. E t Signed x el., Title: Prpci dant- F6P-_-1k Date: April 28, 1984 { Pfi,eART SE ONLY r� Application Accepted by Date ✓� 7 06 Are V_ All I Pit or Grout Inspection by Date Final Inspection b Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT'NO.EH 1324 1REV.)/ J 14-26 L�