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APPLICATION FOR PERMIT SAN ,IOAOUIN LOCAL HEALTH DISTRICT 1 HAIELTON AVE., STOCKTON. CA PAYMENT Telosihnne 1?.091 46Fi-67S) RECEiVEa PI T1Mr7 FXPIRFc + YEAR FROM DATE ISSULI`- O 5 1990 ICnmplete in Triplicate' SAN Appbcaf-on s he,eoy r aro Ito the S.— hntt,ct for a pe,mrt to rpnatruct anti pr vivall tfttftte"t 1,v l'im to f Joel I`,vfwavon n made rn tnmphatk a w•'.s an 1-111 to,sewage or No 1Rty for well Man+p an@f"g0"Vi(j- ir►"wa i'tlrYllt!e5?�•h,aupen Local Health Blewett Road•' Fast (Ni I - , Tracy 286 11C rr Jnb AAdrnt c City-- -- --- tot Sete OwnM•aName Blue Tree Farms Dilate&,, Tracy, CA- 95376 rr...... 111f,- '64-0793 Rancho Cordova, CA 9i Contractor West Hazmat Drill:n;, 3213 Fitzgerald St. _ License No.5Q13$4-C- 71 )1r,-633-7276 TYPE_ OF WE!.LIPUIdP: NE'"WEI t WELL REPLACEMENT I I DESTRUCTION PUMP INS.!LLA ION SYSTEM REPAIR '1 OTHER it Test 11orchole DISTANCE TO NEAREST- SEPTIC TANK SEWER SINES DISPOSAL FLD.— __ PROP ll.'f FOUNDATI-N AGRICULTURE WELL OTHFR WELL __ PITS s"'•'rt; INTENDED_ USE TYPE OF VELL PROBtEMAREA COtISTRUCTION SPECIFICATIONS_ Industrial i l Open B. ,to It Manteca Dia.of Well Excavation __ Dia of Well Casing NA— I I DonoasicIPrivate i 1 Gravel Pacir Tracy Type of Casing-None _ Specd.rahons fl Public OC Other f30t'e 1Jie Delta Depth of Grout Seal _Bottom of Holy pe of Grout cemc. t/1)etlCO rift I I Inrgauon _ AplNnv repth Eastern Surface Seat Installed by_N/A _- Repair Work Done Type of Pump _'i IA Ft P. N/A State Work Done_ N/A Well Desiructoon i I Well Diameter NIA- Sealing Material(top 50'1 _!1/A _ ___ Depth .-- -N/A_ Filler Material I8elthv 50•) _NA_ - --- -- _ - -- - TYPE. OF SEPTIC WORK NEW INSTAL I ATION : REPAIR/ADDITION I I DESTRUC110N I 1No septic system permrr.ed of public sewer ,s available within 200 fee, I (nstaNalion win serve: Residence _ Commercial Other Number of kvirp units: --- Namher of bedrooms- Character of$ol to a depth of 3 fere _ _._ N/A Wath tabs depth SEPTIC TANK IJ Type/Mfg Capacity — No. Compartments _—_- PKG. TREATMENT PLT.1-1 Method of Disposal _- Distance to nearest: Well Foundation Property Lite_.. LEACHING LINE_- 11 No.d Length of lines __NTA _ Total length/sire FILTER RED I I Distance to nnarest: Well ._ _- Foundation_ _ Property Line SEEPAGE PITS 1 I Depth ._ Site -_- �— Number SUMPS I I Distance to nearest. Wellf /1 --.-__-- Fotxtdation _. Property line DISPOSAL PONOS I l I hereby certify that I have prepared this application and that the work will be done Qt acr„rdan-e with San Joaquin county ordinam toe state laws, and rules end regulations of the San Joaquin Local He itth D,ctrrct. Home owner or licensed agent's signatul I rnfhbes the fognwing: "I certify that at the performance of the work for which this permit ro,,stood. I shall riot employ any person rn such mannar.rs to•+&coma suhtact to workman's compentahon lows of California"Contractor'&hiring of suh cnnhachng signature certifies the following. "I certify th d rr the pe lormance of the work for which this pormo is issued.I shall employ persons subject to workman's compensa tion taws of California" The applicant must call for an required nuttecl,ons Cnmplete drawing on reverse side. 5 Signed X �� -_ Title: yD^ 67<=.A `�11 -- Date: _30--Z_-��U FOR ARTMENT USE ONLY �1 L ell Appliutkaa ►ccepted by __ -._.____ _. Dais_�- ��Arsa/�%�_ Gi I / Ph f>.l3roul fn.uetion by —.-•_-- Data _ _ -.._ final Inspection ham.-_�. —.,_,l ._ Dati Additional Coanrrents: -_,- G Stk I66-6781 U Lodi 369.3621 1; Menten 823.7104 b Tracy 8354395 1 Applicant. Return an copies to: Environmental Health Permit'Services 1601 E. Harelton Ave., P.O. Box 2009,Stk.,CA 95201 iN« AMOUNT OUT. AMOUNT RTMITTt'D ( RECEIVED ay +JDAII PERMIT NO / tea 11 N Only, , . ------ -`' ' � 1r4117a 7`r/Ai1SH(7_. ---- i