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APPLICATION FOR PERMIT • <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> red areas such (Complete in Triplicate) <br /> hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> ewage dispo ance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> rnination. D;str ct. <br /> J. Alden Park city Tracy• Ca Lot Size N/A PM <br /> City of Tracy Address 560 South Tracy Blvd. Phone 209 836-4420 <br /> T-T�_� <br /> derson GeotechniC"ddmss 631 Commerce Dr. Roseville a No. Phone(916) 969 88 3 <br /> LL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I rJrdP {�:STALJl^ON ..n SYSTEM RFGAIR ❑ OTHER ❑ <br /> ', <br /> i. <br /> --rb NEAREST. SEPTIC TANK N/A SEWER LINESSe1ll101a B1VdIE;pOSAL FLD. N/A PROP. LINE �0-30 <br /> FOUNDATION 30-40' AGRICULTURE WELL) mile OTHER WELL 1500 r PITS/SUMPS /�A <br /> lip USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4" <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> —4-- -- iwrivate CS Gravel Pack IN racy Type of Casing PVC, Specifications <br /> l�nitOringCl Other ❑ Delta Depth of Grout Seal 7feet Type of Grout 2 o Bent <br /> __. Anderson Geotechnical Consultant <br /> 2r LApprox. Depth p Eastern Surface Seal Installed W <br /> --' --4Done O Type of Pump NA H.P. N/A State Work Done N/A - <br /> -3' Bentonite Seal U 2a Bentonite Gro t <br /> 4xion ❑ Well Diameter 41r Sealing Material� '1 <br /> Depth F;Iler Material 1 #3 sand below Bentonite Seal . <br /> -t - <br /> -i —IF-TIC WORK: NEW INSTALLATION C REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permirled if public sewer is <br /> - available within 200 feet) <br /> -- -�'-1will serve: Residence_ Commercial_ Other <br /> ' tk living units: ._ Number of bedrooms <br /> I of soil to a depth of 3 feet: Water table depth <br /> -jr, ❑ Type/Mfg _ CapacityNo. Compartments <br /> * Method of Disposal <br /> -_..�. _.. .._I.. . ENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line f <br /> NE ❑ No. 6 Length of lines Total length/size <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> •?S ❑ Depth Size Number <br /> ❑ Distance to nearest: Well Foundation _ Property Line <br /> NDS ❑ <br /> that I have prepared this application and that the work will be done in accordance with San Joaquin county ord-nances, state laws, and <br /> j lations of the San Joaquin Local Health District. <br /> Dr 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 <br /> son in such manner as to become subject to workman's compensation Laws of California." Contractor's hiring or subcontracting signature <br /> _ I lowin certify that in the performance the work for which this permit is jawed, I shall employ persons subject to workman's compensa <br /> a' rnia." <br /> must call f e ii . Complete drawing on reverse side. <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> _ opted by <br /> Date Area <br /> Inspection by <br /> Date Final Inspection by Date <br /> _— ments: <br /> 1 ❑ Lodi 3833621 ❑ Manteca 8237104 ❑ Tracy 835-6385 <br /> urn all copies to: Environmental Health Parml/Services 16DI E. Hazelton Ave., P.O. Box 20109, Stk., CA 95201 <br /> FEEK s RECEIVED BY DATE PERMIT N0 <br /> INFO . <br /> AMOUNT DUE AMOUNT REMITTED CASH <br />