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•APPUGAMCN FOR PEiiR+II'd • <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �- + , 1�HAZELTOe AVE., S -6781 N, CA <br /> ' r dP'�'�"►" f Telephone (209) 466-6187 <br /> It tAVeo%A. PERMIT XPIRES 1 YEAR FROM DATE ISSUED <br /> Si/4A[SC��y►j _/� (Complete in Triplicate) <br /> .'e heryl mimide to the Safi oaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> mmlitance 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 /> District. - - <br /> Alden Park clfy Tracy. Ca Lot Size N/A PM <br /> Name � <br /> City of Tracy. Address 560 South Tracy Blvd. phone 209 836-4420 <br /> Anderson GeotechnicalMdres9 631 Commerce Dr. RoseviLlMhse N G�y9one<916) 969-88 3 <br /> S WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION Q Or;{OC I <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 20-30 t <br /> ICE TO NEAREST: SEPTIC TANK N/A SEWER UNEsSe41101a BlydisPOSAL FLD, N/A PROP. LINE _--. <br /> FOUNDATION 30-40' AGRICULTURE WELLS mile OTHER WELLISOO' PITS/SUMPS 1A <br /> :NOED USE - TYPE OF WELL ""PROBLEM A'b DNSTRUCTION SPECIFICATIONS 415 <br /> ,dal ❑ Open Bottom Cr7.Manteca Dia. of Well Excavatlon C <br /> Dia. of Well Casing <br /> �1 T of Casing Specifications <br /> c/Private Gravel Pack i Tracy Type g ` <br /> monitoring❑ o r S Il Ei.0 ❑iDelta Depth of Grout Seal Meet Type of Grout 2% <br /> on �prox. Depth E Eas4r�i- • Surface Seal Installed by Anderson Geotechnical COriSllltarit <br /> 1 H Pa ,� State Work Done N/A <br /> rylork Done ❑ ype of Pump _,-N/ -- <br /> I'4" Sealing Materia 1 �'�' BentOni e Se^1 F 24 Trite2l�te� Gro it' <br /> atmction ❑ Well Diameter _ t� g � #3 sand below Bentonite Seal. <br /> Depth, I Flier Material <br /> OF SEPTIC WORK: NEW INSTAL TION U REPAIR/ADDITION U DESTRUCTION LJ io aveptic syst m feetif pubiic sewer is <br /> aila <br />! ton will serve: Residehce_ Comrnerelel�k Other <br /> r of living units: _. Nu11 mbecdf bedrooms <br /> t Water table depth <br /> Iter of soil to a depth of 3,101: No: Compartments <br /> TANK C TyMfg Capacity <br /> pe/ <br /> Method of Disposal <br /> TREATMENT PLT' ❑ <br /> Distance to nearest: Well - Foundation_ Property Line <br /> Distance <br /> Total length/size <br /> }TING LINE Cl No & Length lines Property Line <br /> c BED ❑ Distance to nearest: Weil Foundation <br /> 4GE PITS ❑ Depth Size Number <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> ..SAL PONDS ❑ <br /> certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> and regulations of the San Joaquin Local Health District. for <br /> owner orslone n such manna gas tore certifies the b come sub eototo woorkrman's c mllowing: "I certify tpensation chat in the laws Of Califorrnia." Conrformance of the tractoeslhir ng orr sub-cont act ng signlata e <br /> any pe <br /> +es the person <br /> i certify that.a o pXllm3ncethe work for which this permit is issued, I shall employ persons subject to workman's eompensa- <br /> follow <br /> rtrrrs of Ca' rnia." <br /> tiaplic must call f s lete drawing on reverse side. <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY 7 �fye <br /> Date 3 �' Aree --- <br /> exdcation opted by <br /> a Grout Inspection by <br /> Date -Final Inspection by Date <br /> i <br /> W;onal Comments: <br /> Sit 46&6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 8956385 <br /> adcant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> r a RECEIVED By DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH <br /> INFO Jam/ S- 0 Ito Y`3—F7 <br /> RPR'.rn.� ��/ �' J .� Ot�3' <br />