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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PE IT EXPIRES 1 YEAR FROM DATE ISSUED A(dOo --- ----- MICR 0 5 1990 (Complete in Triplicate) SAN JOAQUIN (;I;LINTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install tion is made in compliance with Sari Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump anPr"RMM(rNg1"pAt."IV gftJoaquin Local Health District. Job Address Blewett Road; East of I-5 City Tracy Lot Size 286 acres PM Owner's Name Blue Tree Farms Address Tracy, CA 95376 Phone 916-364-0793 _—_ — Rancho Cordova, CA 95742 West Hazmat Drilling Address,_3233 Fitzgerald St. License No.501_384-C-57phone916-638-7276 Contractor -------------------- ------ -------------- - — TYPE OF WELL/PUMP: NEW WELL U WELL REPLACEMENT Cl DESTRUCTION I I PUMP INSTALLATION ❑ SYSTEM REPAIR f) OTHER pq Test Borehole 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 I1 Industrial 1-I Open Bottom I I Manteca Dia. of Well Excavation _ Dia. of Well Casing NA I I Domestic/Private I Gravel Pack I I Tracy Type of Casing None _ -- Specifications I'I Public IQ Other Boreholel 1 Delta Depth of Grout Seal —Bottom of Fype of Grout Hol Cement/bento ite _ I I Irrigalion _ Approx. Depth I I Eastern Surface Seal Installed by— N/A - Repair Work Done I I Type of Pump _NJA H.p. N/A State Work Done _ N/A �I Well Destruction I 1 Well Diameter NA Sealing Material (top 50') _ N/A _— Depth —NSA Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No seplic 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 1.1 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE I l No. & Length of lines N _ Total length/size— \ FILTER BED I I Distance to nearest: Well Foundation Property Line I -- — - SEEPAGE PITS I I Depth —_ ___ N Size Number SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I I 1 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: "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 must call for all required inspections. Complete drawing on reverse side. Signed X _ Title: Date:��U ��_��4 �_ Date: -Z FOR ARTMENT USE ONLY Application Accepted by Date ✓ Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 1-1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ 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 CASHV CK RECEIVED BY DATE /)1 //P►►ERMIT NO. EH 1142e LIOL��[ 3-211NEV.VNSI EH � 1—/1/—L/((� / /