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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL—i ON AVE., STOCKTON, CA 2 198 Telephone (209) 466-6781 d NVfRp? PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F�WIVSERVICFS0ENTAL ti,,Al {Complete in Triplicate} 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 Local Health District. Job Address 19370 W . GRANTL I NE RD. City TRACY Lot ize PM Owner's ame CLINTON MAPLES Address 238 MAVIS DR. PLEA NTON Phone 415 462•-4995 Contractor Address 15? P F 1 A N D A L E AV-E__Lice e No. �Q$1�Phone 4 – 1 5 TYPE OF WEL /PUMP: NEW WELD}( WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TON REST: SEPTIC TANK 0 0 r + SEWER LINES 1001 + D POSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL THEIR WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION PECIFICATIONS ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Ex ation Dia. of Well Casing 6° [X Domestic/Private Gravel Pack [A Tracy Type of Casin PVC Specifications ❑ Public ❑ her ❑ Delta Depth of Gr t Seal 100 r Type of Grout ❑ Irrigation prox. Depth ❑ Eastern Surface S I Installed by LING CO. INC. Repair Work Done ❑ sT of ump H.P. State Work Done Well Destruction LE] Diam er Sealing Materia;el:w p 50'D W h Filler Material l 501 TYPE OF $E WO EW INSTAL TIO REPAIR/ADDITIO ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installatio will Re ' e— C ercial_ Other Number o lig It Numbe of be oms w Character a of 3 feet Water table depth SEPTIC TAN Type/ g Capacityw No. Compartments PKG. TREATM PLT. ❑ Method of Disposal D' ante to nearest: Well Foundation Property Line 4 LEACHING LINE No. & Length of lines Total length/size FILTER BED Distance to nearest: 7411 Foundation Property Line SEEPAGE PITS ❑ Depth ISize Number SUMPS ❑ Distance to nearest: Wellundation Property Line DISPOSAL PONDS El I hereby certify that I have prepared this applic/ies n and that the work will be ne in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Locaalth District. Home owner or licensed agent's signature cert the following: "I certify that in t performance of the work for which this permit is issued, I shall not employ any person in such manner as to beco a subject to workman's compensation ws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the Pe ormance of the work for which this permi is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required in ctions. Complete drawing on reverse side. Q Signed villa: ' Date:FOR DEPAR MENT USE ONLY Application Accepted by Date g 8 Area r � 1nsAIl,,2� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: e✓n �"'`*� �", ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 8237104 ❑ 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 ;CAS RECEIVED BY DATE PERMITNOINFO H + EH 13-24{REV,t i 5} /ti F, .66 EH 14-29 r� I