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t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT _ �* - 1601 E. HAZEL T ON AVE., STOCKTON, CA 16i 5 w + i , Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work ergirV1&,&gibed This applicktfgrj is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Reg►ha[i6Vs;)f ttip.)ZanJoaquin Local Health District. Job Address 502 East Grantline Rd. City Tracy tot Size PM 16th Floor Owner's Name pacificaGas & Electric Address 1 California, San Francisco ICA Phone (415)972-7095 Contractor NSA T�4' fir'- Arens N/p' License No. N�A Phone NSA TYPE OF WELL/PUMP: NEW WELL LX WELL REPLACEMENT ❑ DESTRUCTION ❑ Qtf PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ' 1QN 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 Orr ❑ Industrial ❑ Open Bottom 71 Manteca Dia. of Well Excavation 8 Dia. of Well Casing IX Domestic/Private ® Tracy Type of Casing seh 40 pvc Specifications f`l Public Other rK vi Cl Delta Depth of Grout Seal 4 feet Type of Grout cement ben ite I i Irrigation 4OU tApprox. Depth I I Eastern Surface Seal Installed by Pacific Gas & Electric Co. _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION l I DESTRUCTION ! 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 Character of soil 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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." The applicant t call for ail required inspections. Complete drawing on r verse side. L1 41 Signed X ZU Title: ��_ I.S7— 1 Data: AI/ 0 r'1 -t �OYI 1� fT��' -F6 r-5 Af�TMENT USE ONLY/��`g� py��p1/ "- �jAA.5,01 Application Accepted by ' Date h p_0 Area Pit or Grout Inspection by Dat Final Inspection by Date '07r 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 2DD9, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-24(REV.t/115) l EH 14-26 R '