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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DIS T 1601 E. HAZEL T ON AVE., STOCKTO CA [Py Telephone (209) 466-6781 ��JJJ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. Grant Line Road West of Paradise Road Job Address Parcel #237-300-1 and 213-070-43 City Tracy Lot Size 154 acres + PM acres 7317 611r_,4-Hkr_ X35— y3 6 Owner's Name '� � Address 1QQ SFi 3='=__ - �---�- Phone �+i��z•—yv�1 2855 Campus Drive, Suite 300 Contractor__Earth Metrics Inc, Address San Mateo, CA 94403 License No. Phone 415-578-990 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER subsurf ace invest gation/soil borin s 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 Ll Industrial N/A ❑ Open Bottom N/A ❑ Manteca Dia. of Well Excavation_N/A Dia. of Well Casing _N/A (l Domestic/Private ❑ Gravel Pack IX Tracy Type of Casing N/A Specifications (1 Public 1-1 Other ❑ Delta Depth of Grout Seal _N/A Type of Grout__ NPA__ I I Irrigation -__ Approx. Depth I I Eastern Surface Seal Installed by K/A _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is N/A avai►`�I I Installation will serve: Residence_ Commercial_ Other ... �rP.R � .J Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity TIA Aral Cojg@f�ents \ PKG. TREATMENT PLT. ❑ Method of Disposal ..v Distance to nearest: Well Foundation Property Line r� ENOR01 S1M.EN_1AF1JFAT_TFFI U LEACHING LINE N/A ❑ No. & Length of linesTotal lengt /size mmcm FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS N/A I I Depth Size _ Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS (l 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title: Praci dP_nt Date: April 28, 1989 FOR 1 RT SE ONLY Application Accepted by Date — ? 7 / Pit or Grout Inspection by Date Final Inspection b Date __ Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 0 Manteca 823-7104 O 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 RECEIVED BY DATE PERMIT'NO. INFOEH 13-24 ,- + EH 11.28(REV. i x si •GYv I�o Og �A IS9 —`,