SITE INFORMATION AND CORRESPONDENCE

Home Browse Search

\J APPLICATION FOR PERMIT VMIZNT L �P� ®� SAN JOAQUIN—LOCAL HEALTH DISTRICT RECD VED �V 1601 E. HAZE I ON AVE., STOCKTON, CA J\��0�Q-�� Telephone 1209) 466-6781 G'[P 18 1989 �j.��Q. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED y7 16�44G (Complete In Triplicate) INVIRONMENTAL HEALM :gej � h' Applica t keieby made to the San Joaquin Local Health District for ruct and/or install the work herRr, escri S ;CEpalication is made in com liance with San Joaquin County Ordinance No. 549 for. g r o. 1 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 26700 South Banta Road City Tracy Lot size 5 . 8 ac. PM Owner's Name All Pure Chemical Address Same as above Phone 209-835-5423 Spectrum Ex lor. Stockton 512 Contractor p Address Ucense No. 512 2 268 phone 209-465-8 l: TYPE OF WELL/PUMP: NEW WELL ?f WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTAL TON n SYSTEM REPAIR ❑ HER{ ;_"J-/ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES ft None ISPOSAL FLD.2 f PROP. LINE 70 ft, * FOUNDATION AGRICULTURE WEI . MiAER WELL 3 f PITS/SUMPS Adj . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 11Open Bottom ❑ Manteca Dia. of Well Excavation 4 1 ri. Dia. of Well Casing ❑ Domestic/Private �E Gravel Pack _'(� Tracy Type of Casing S C H 40 PVC Specifications F1 Public f-1 Other F1 Delta Depth of Grout Seal 10-12 f t . Type of Grout Cem/Bent . I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Spectrum Exploration Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is O available within 200 feet.) C Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 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: Well Foundation Property Line t SEEPAGE PITS I I Depth Size Number SUMPS - Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: -11 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.' The applicant must c�for a req ./iiinspections. Complete drawing on reverse side. Signed X / �� Title: _ L1� �� -t�GLC(-1< < Date: R DEP RT ENT USE ONLY Application Accepted byZ '� Date Pit or Grout Inspection by Date /UFinal Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 C Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Sarvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 � �-z33v FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY DATE PER NO.