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r JAPPLICATION FOR PERMIT N'C OAaUIN LOCAL HEALTH DISTRICT � ��S0 GNL � pxq1 1601 E. HAZEL T ON AVE., STOCKTON, CA �Gf' O��%3AVA N � � Telephone (209) 466-6781 1� � SNV4 igbtA -AxO l PERMIT EXPIRES 1'YEAR FROM DATE ISSUED `•�� P��-� (Complete in Triplicate) QN��tN �JiGES Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hereir �b�lis5�pplication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R gulati of the San Joaquin Local Health District. Job Address y 1420 N. Trac Blvd. Cit Tracy Lot Size PM — Tracy Community , Owner's Name Memorial Hospital Address 1420 N. Tracy Blvd. , Tracy,, CA Phone (909835=150 - 2825 'E: Myrtle Contractor Spectrum Exploration Address Stockton, CA License No-C-57-5i2268Phone (209) 465-8712 TYPE OF WELL/PUMP: NEW-WELL-0- 3_3 WELL REPLACEMENT ❑ DESTRUCTION ❑ t PUMP INSTALLATIOND SYSTEM REPAIR'❑ OTHER40IMonitoring._ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LINE.'— FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ❑ Industrial . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2" j IR Domestic/Private M Gravel PackIR Tracy Type of Casing Schedule 40 PVC Specifications t� t"1 Public M Other Delta Depth of Grout Seal 91 17-1Type of Grout cement a Spectrum Exploration en oni i I Irrigation - _.-Approx. Depth 1.1 Eastern• Surface Seal Installed by p _ ' NA H p NA State Work Done_NA Repair Work Done L1 Type of Pump Well Destruction ❑ Well Diameter 211 Sealing Material (top 50') 0.030 sand 30-9' • bentonite seal 9-6' ' NA cement bentonite s urry 6-61 Depth 30 Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION 11%.REPA4134ADDITION LI DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) r n Installation will serve: Residence Commercial Other Number of living units: Number of bedroa`ms - Y ` Character of soil to a depth of 3 feet: Water table depth - r _ SEPTIC TANK, ❑.. Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT- ❑ Method of Disposal Distance to nearest: r Well' Foundation-- .Property.Line LEACHING LINE ❑' No. & Length of lines ` Total length/size FILTER BED ❑ Distance to nearest: "' 'Well "' -Foundation Property Line ' SEEPAGE PITS i I Depth Size Number SUMPS - D Distance to nearest:" Well Foundation Property Line " DISPOSAL PONDS ❑ Y 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 DiMrict.' - 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 F 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- E tion laws of California." t The applican t call for all requ'ed ins cti S. Complete drawing on reverse side. T SA14313AMIN LOCAL. HEALTH DISTRICT ' ,E DNIAINTAL HEALTH DIVISION Signed X Title: t q - SPEL T ER?A ' FOR DEPARTMENT USE NLY Application Accepted by Date Area Pit or Grout Inspection by {{ Date p � Final Inspection by Date ` 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 T' FEE- AMOUNT DUE AMOUNT REMITTED CCkRECEIVED BY DATE PERMIT NO. INFO ♦.EH 13-24 IREV. /H 51 T �``7/gcj F59-LI tot. EH 10-28