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>wool APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZEL T ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 C0 j �� SAN JOAQUI�' G��i>>4fY (Complete in Triplicate) PUBLIC HEAI.i r,? ""OHS Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w6W4WNMW i&ed.,This�ap0M&Q1 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 13170 Grantline Road City Tracer Lot Size 62 acres PM Owner's Name etilo_pment Address 3600 Pruneridge AVe., Ste. 100 Phone 408 243-3200 Santa Clara, CA 95051 Contractor H Address 3242 Brennans Rd. Lcerise No. 401530 Phone 916165 2-4640 TYPE OF WE MP: NE ®(2) WELL REPLACEMEN DESTRUCTION D PUMP LLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DIST CE TO NEA T: IC TANK - SEWER LINES - DISPOSAL FLD. - PROP. LINE - FO DATION - AGRICULTURE WELL - OTHER WELL1 PITS/SUMPS INTENDED T E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I i Industrial v Open om ❑ Manteca Dia. of Well Excavation 81f Dia. of Well Casing 411 Ix 04,44404AV6 ❑ Gr ac k] Tracy Type of Casing-411 sch 40 PVC Specifications IIIOj?ifor f� Delta Depth of Grout Seal 12 1 Type of Grout-C-eIMLent _ I"i a Ic r San I I Irrigation 25 IApproPr.�th I I Eastern Surface Seal Installed byHogate Drilling Co. _ Repair Work Done ❑ Type of Pump - H.P. - State Work Done _ Well Destruction ❑ Well Diameter 41tg Material (top 501 Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATI REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is 0000� available within 200 feet.) Installation will serve: Residence_ Com Number of living units: Number of bedroocial Other Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 0000, Method of Disposal Distance to nearest: Well ounda tion Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L] 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 lawsof fornia." The applican m s 11 for all required inspections. Complete drawing on reverse side. aht...-....z.e....>..,.x Signed x u11— Title: CEG 1136 Da .September 17, 1990 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: U 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. ♦ EH 1 3.24 1 REV.I/H 5) EH 14-26