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3 APPLICATION FOR PERMIT ¢ SAN JOAQUIN LOCAL HEALTH DISTRICT o- �, 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 �+ PERMIT EXPIRES 1 YEAR FROM DATE IS SUEWI!5 1/ 14-1 M L (Complete in Triplicate) tr�Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th��`'h rein described- This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the FMlds Wd,` *89'ns of the San Joaquin 3. 1_ocal Health District. 1O Job Address 229 Moffat Rl yd_ City Manteca _ Lpt izN,,MtNTAt�y , pM 4 CY41 5) .J Owner's Name Gc)l den Grain (In Address 1 1 39th Ave - San Lea 1dYf{hjone — 179 1401 Halyard DR, Ste. 140 c57 { 916} Contractor Groundwat t-r Tech _Address West _ Sacramento- License No. 4'1 d d�Phone TYPE OF WELL/PUMP: NEW WELL I9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES DISPOSAL FLD. -- PROP. LINE 5 FOUNDATION __5_r AGRICULTURE WELL -- OTHER WELL -- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation 7 .51r _ Dia. of Well Casing r� ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing PVC Specifications bentonite/ -1 Public i_l Other ❑ Delta Depth of Grout Seal 8 } , 6 3' Type of Grout_ce ent/San d I I Irrigation 701 , 5-Q-r Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 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 1.1 REPAIRlADDiTION I I DESTRUCTION I 1 INO septic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence_ Commercial— Other t Number of living units: Number of bedrooms M Character of soil to a depth of 3 feet: Water table depth t 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: Welt Foundation Property Line SEEPAGE PITS l 1 Depth Size T _ Number SUMPS L1 Distance to nearest: We 11 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 Di?trict. 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 istion laws laws of California." ENVIRONMENTAL HEALTH DIVISION The applicant must call for all required inspections. Complete drawing on reverse side. SPECIAL lli L PERMIT MT Signed X - Title: Geologist f P"* Date: 1 0/23/89 FOR DEPARTMENT USE ONLY Application Accepted by Date �a/ZL��_ / Area Pit or Grout Inspection by �� Date Final Inspection by Date Additional Comments: 0 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 INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. + EEH H N-241REV.Ii115) 35, IJV 3�f q0