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APPLICATION F014 PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA -3 l Telephone (209) 466-6781 / ,Q /v1."—A_e_ PERMIT XPIRES 1 YEAR FROM DATE ISSUED lyr 5a0 SC7Ssj/SoMES�7 (Complete in Triplicate) Application is heretfy made to the SarG/a4in Local Health District for a permit to construct and/or install the work herein described. This application is f' 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. Job Address Alden Park City Tracy, Ca Lot Size N/A PM I Owner's Name City of Tracy__-_ Address 560_South Tracy Blvd. -- �j Phone 209 836-4420 Contractor Anderson Geotechnicabddr,ss 631 Commerce Dr. Roseviilgh,e Ne:� y/�en�(916) 969-88 3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION rRO rt 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER' 6v.%' 'O(- DISTANCE TO NEAREST: SEPTIC TANK N A SEWER LINESS911 B1V�16POSAL FUD. N A - LINE 20-30 r i FOUNDATION 30-40' AGRICULTURE WELL' Mile OTHER WELL 1$00 r I, PITS/SUMPS _LA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS *. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4t1 ❑ Domestic/Private X Gravel Pack IN Tracy Type of Casing PV(' Specifications W PG1m6 monitoring,i Other ❑.Delta Depth of Grout Seal 7f et u t Type of Grout 2' , ❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by Anderson Geotechnical Consultant Repair Work Done ❑ Type of Pump H.P. N A State Work Dane_ N/A _ Well Destruction I I Well Diameter n —4 Sealing Material) 7-3t $ 71 OnttP $Prtl F 2°3 rOni to Groit Depth _ Filler Material Cfi ')It3 Sand below Bentonite Seal _ TYPE Or SEPTIC WORK. NEW INSTALLATION ❑ REPAIR/ADDITION Ll DESTRUCTION ❑ (No septic 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: - Water table depth SEPTIC TANK CI Type/Mfg -__ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth SizeNumber SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followin " eertify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's componsa- lion laws of Ca' rnia." The applic must call f e ti Complete drawing on reverse side. Signed _ _ Tide: _. Date: FOR DEPARTMENT USE ONLY �j Application epted by _ c, u t/ Date 3 ^87 Area. i Pit or Grout Inspection by Cl,. f'� V 0 1 'rli.'bgte y' 4_c Fift I Inspection by Date . Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8366385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DTE PERMI7'NO INFO H A EH 1324(REV EH 16)11