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X APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ; "i 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RI RIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAR 0 r 1990 (Complete in Triplicate) SAN JOAQUIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tl 4(D+* ti •i9f ,fV4t&plication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump ang MV$Tft"�Atrp+pbf NJoaquin Local Health District. M Job Address Blewett Road; East of I-5 city Tracy Lot size 286 acres PM j Owner's Name Blue Tree Farms Address Tracy, CA 95376 Phone 916-364-0793 f Rancho Cordova, CA 95742 Contractor West Hazmat Drilling Address 3233 Fitzgerald St. License N0.501384-C-570hone916-638-7276 TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ® Test Borehole k DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation W, Dia. of Well Casing NA I� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing None Specifications M Public A other Borehole❑ Delta Depth of Grout Seal Bottom of HOIType of Grout cement/bento rte I I Irrigation —..Approx. Depth t I Eastern Surface Seal Installed by NSA fRepair Work Done ❑ Type of Pump N/A H.P. NSA State Work Done _ N/A r Well Destruction CI Well Diameter N/A Sealing Material (top 501 N/A Depth N/A Filler Material 16elnw 50') N/A V TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1.1 DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: N�A Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line j. LEACHING LINE ❑ No. & Length of lines N/A Total length/size \ f FILTER BED ❑ Distance to nearest: Well Foundation Property Line r MSEEPAGE PITS l ! Depth Size N/A Number SUMPS Ll 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,`1 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 compansa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: SQA l0 P_A k f 'I S Date: —3�Z Y 9 o FOR ARTMENT USE ONLY /'7 r Application Accepted by Date -3 � G ` v Area Ile Pit or Grout Inspection by Date Final Inspection b DateQ I Additional Comments: ❑ 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 CK CASH RECEIVED BY DATE PERMIT"NO. G I t.EH 13-24(REV.1/H 5) � � 7�� ' ��(�� f'()-�f�