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' - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -' CWfC,E` Fd2 at _4 WEcy 1601 E. HAZELTON AVE., STOCKTON, CA Q saP;�c 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 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. - —197_ Job Address Northeast Intersection of Clover Rd. & city Tracy Lot Size 232' x 375' PM Tracy Blvd. ` owner's Name . State Farm Insurance Address c/o Castillo Co. , P.O. Box 210$Zone {602)231-9000 f 5729-F Phoenix, AZ H13111 85036 k Contractor BSK & Associates Address Sonoma Dr P License No. 490942 Phone_415-'462-400 TYPE OF WELL/PUMP: NEW WELL ❑ WELL FIEPLACIEWNT ❑ DESTRUCTION ❑ t PUMP INSTALLATION'O SYSTEM REPAIR ❑ OTHER :n Geotechnical DISTANCE TO NEAREST: SEPTIC TANK,_ -- SEWER LINES y 100' DISPOSAL FLD. -- PROP.BoriL NE ng550 :� -- FOUNDATION AGRICULTURE WELL -- OTHER WELL -- PITS/SUMPS "' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom E1 Manteca Dia. of Weil Excavation Dia. of Well Casing ❑ Domestic/Private {❑ Gravel Pack ❑ Tracy Type of Casing Hollow -Stem Specifications' € n-Public �a n Other r ❑ Deltas` Depth of Grout Seal 20 r Type of Grout_7 5a-c-k I I Irrigation - _Approx. Depth I 1 Eastern -Surface Seal Installed by Cement' Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth -- Filler Material (Below 50') _ TYPE OF SEPTIC WORK: NEW INSTALLATION_) 1 REPAIR/ADDITION l 1 DESTRUCTION I 1 (No septic system permitted if public sewer is N/A t e available within 200 feet.) Installation will serve 'FiM86nce.. Commercial_ Other Number of living units_: Number-of bedrooms Character of soil to a depth of 3 feet:~ + Water table �.: SEPTIC TANK ❑ "Type/Mfg" Capacity No. Camp _ PKG. TREATMENT PLT. ❑ ti } Method of011sposal Distance to nearest: Well Foundation Property.Line 1 E I f 9�n�r� ■ _ ju a N/A LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ENVIRONMENTALHEA!TF ' PERMITISERV.ICV• SEEPAGE PITS I 1 Depth Size _ Number N/A SUMPS - L��-Distance to nearest: Well Foundation Property Line DISPOSAL PONDS � "F'"•'� j 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, an rules and regulations of the San�Joaquin Local Health Dliltrict. 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 El 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." c The applicant us call for II required inspecti ns. Complete drawing on reverse side. Signed X w v .-2:;7��'i---��— Title:Manager-Geotechnical Svcs. Date: 6/29/89 Alex Y. .Eskandari T FOR EPARTMENT USE ONLY j Application Accepted by Date 1,1 rea Pit or Grout Inspection by Data Final Inspection by 1 to (7 1 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 DUE" ^� AMOONT REMETTED K RECEIVED BY " DATE PERMIT NO. INFO +.EH 13.24/REV.$iH5) EH 14-26