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h APPLICATION FOR PERMIT SAN JOAQUiN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO, TLOO O Telephone (209) 466-6781 DATE ISSUED 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. 1 t Job Address 26900 So. Hansen Rd., Tracy, CaWda v 95a76 me fry r Owner's Name ceder ek Ar Robertson AddressP.O,Box 1082 Tracy, Calif,95 76 Ph(r*1 7-6787 .� Contractor's Name Hone License No. Phone 0 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑I PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑I DISTANCE TO NEAREST: SEPTIC TANK over 100 ftJWER LINEover 200 ft. DISPOSAL b#er 'aQO MQP. LINK)Ver2.00 ft, FOUNDATION over ]�6RICULTURVK • OTHER WEL9yer �Q f�1dS/SUMP9VEr a,QQ ft. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U Open Bottom ❑Manteca Dia. of Well Excavation 13 in• 9r-F1!qP§q__vliture K] Gravel Pack ❑ Tracy Dia. of Well Casing 8 in. I] Public ❑ Other ❑ Delta Type of Casing PVC, Class 200 Irrigation Approx. ❑ Eastern Specifications [:] Cathodic Protection Depth Depth of Grout Seal 50 ft, GeoPiivv'eersWo(a)k I Ej-ethresen an future agricultural) ype of Grout Bentonite wateri & sanitation• irri ti0 urface Seal Installed by Tenni s BIOS. Modest©, Cal, Repair Work Done ❑ Type of Pum ut er8 ei.P. 3 State Work Brm -to be done: Fabrication and ins ll. Well Destruction ❑ Well Diameter Sealing Material (top 50') of lump System, incllxtI ink a ectrical Depth Filler Material (Below 50') service and well hggd—atlucture there Or. TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM ❑ Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑I 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 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); compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is tissued, I shall employ persons subject to workman's compensation laws of California." The applicaF�.�U ;el a r fired inspections. Complete drawing on reverse side. Signed X T�.�z/ Title: Cr4TI1$2' Date: D Application Accepted by ARTME USE ONLY Area c7l � ❑ Stk 466-6781 L_ Additional Comments: ❑ Lodi 369-3621 Pit or Grout Inspection b Date ❑ Manteca 823-7104 Final Inspection by Date .2 ❑ Tracy 835-6385 Applicant - Return all copies to; ironment Health Permit/Services IMI F. 'Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO H EH 13-24 REV. 10/82 10/82 500 14-26