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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 i 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. Job Address 1420 North Tracy. Boulevard Trac City Lot Size PM _ Owner°s Name Tracy Community Address 1420 N. Tracy Blvd. P-Tracy, CA Memorial Hospital 3825 East Myrtle Street, Phone 209 835-15Q0 Contractor Spectrum Address Stockton, CA 95205 51.2268 (2 License No. Phone 09)948-13 5 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION'❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L4 SOil Boring (2) I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .5 to 10 ftOISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation L1 Domestic/Private 0 Gravel Pack ❑ Tracy Dia. of Well Casing Type of Casing Specifications M Public n Other ? n Delta Depth of Grout Seal I I Irn ation Type of Grout g _,_.Approx. Depth I ) Eastern Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. - State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Backfill Cement bentonite slurr lop, Depth 6" borin s 15�iller Material (Below 50°) Y. TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDiTION I I DESTRUCTION I f iNo septic system permitted if public sewer is Installation will serve: Residence— Commercial____ Other available within 200 feet.) V Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK. Water table depth PKG. TREATMENT PLT. ❑ Type/Mfg -. Capacity No. Compartments E1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines FILTER BEDTotal length/size ❑ Distance to`nearest: Well Foundation Property Line , SEEPAGE PITS I I Depth Size SUMPS Number 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 C` rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: -1 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 laws of California." The applicant 5pqall for all re ire in pe tions. Complete drawing on reverse side. Signed Title: /n�„ Date: - sv FOR DE RTMENT USE ONLY p Er Application Accepted by Date Areas ` , Pit or Grout Inspection by Date Final Inspection by 'Zfu ?., Date Additional Comments: / ❑ Stk 466-6781 D'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 AMOUNT DUE ;AMOUNT REMITTrCAINFO RECEIVED BY DATE PERMIT-NO. +.EH 13-24(REV.kix51 3 -olU S,r�c� �oZ/ g_S�/ 69 EH 14-16