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f r APPLICATION FOR PERMIT`.,;, SAN JOAQUIN LOCAL HEALTH DISTRICT"" 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 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 corurtructand/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 Regulatkxm of the San Joaquin Local Health District. Job Address 8715 West Grant. Line Road Tra&W - uiteS 3 PM 5.35 min00 c/o Kapraelian Engine, 1g Nlaxtinez , CA 94553 Phone 415 228-1882 Owner's Name Exploration Geoservices San Jose , CA (408) Contractor_ Inc. _Address I 1 7 5 C 1 i rI u r, AV-.e-_License No._4,S_42_8$.C_t)-,_Thone 295-4 2(11 TYPE OF WELL/PUMP: NEW WELL R WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS NIA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation At' Dia. of Well Casing r1 IX Domestic/Private Gravel Pack ❑ Tracy Type of Cast PVC Specifications ❑ Public !K Other Monit0T❑ Delta Depth of Grout'Seal 51 min, Type of Grout Concrete ❑ Irrigation X54 prox. Depth ❑ Eastern Surface Seal Installed by Contractor Repair Work Done ❑ Type of Pump H.P.. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 5(Y) Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INS LLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ o septic system permitted if public sewer is available within 2DO feet.) Installation will serve: Residence_ mercial Other 4 Number of living units: Number of ooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg pacity 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: ell Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to rest: Well Foun ion 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."Contractoes 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 q 'fornia.I' The applicant mus all for all r fired inspections. Complete drawing on reverse aide. Signed -itle: Engineering GCO109i.st . Date:., 5120Z86 _ i ' r I FOR DEPARTMENT USE ONLY i i Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca SM-7f6i ❑ Tracy Applicant - Return all copies to: Environmental.Health Permit/Services 1601 E. Hazehon Ave.,P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C H RECEIVED BY DATE PERMT',NO. ` INFO . EH 1324(REV.s/a 5) EH W25 �J v ,y I � 5 1 ,;..• r i