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• APPLICATI N F R PERMIT V✓ser / Y SAN JOAQUIN LOCAL HEALTH DISTRICT ().y y/71 � / 1601 E. HAZELTON AVE., STOCKTON, CA W¢ 3 °� y i F do," Telephone (209) 466-6781 /,r(ffp-to PERMIT XPIRES 1 YEAR FROM DATE ISSUED $bp -S4C ?y/SOM0 S7, (Complete in Triplicate) Application is heretfy made to the Sart JtSagtln 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. Job Address Alden Park city Tracy, Ca Lot Size N/A PM Owner's Name City of Tracy_ _ Address 560 South Ta rcy Blvd. �jyyPhone 209 836-4420 Contractor Anderson Geotechnica]nddress 631 Commerce Dr. Roseviilghse No:� -�-,"bene<916) 969-88 3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER M ON Jov DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINESSeQ a BlA16POSAL FLO. N A ROP. LINE 20�-'30' FOUNDATION 30-40' AGRICULTURE WELL1 mile OTHER WELL 1500' PITS/SUMPS /�A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 411 ❑ Domestic/Private 03 Gravel Pack IN Tracy Type of Casing PVC Specifications In Rom monitoring❑ Other ❑:Delta Depth of Grout Seal 7feet Type of Grout-2-9g' Bentgnit . ❑ Irrigation 2_c-1 Approx. Depth 0 Eastern Surface seal Installed by Anderson Geotechnical Consultant Repair Work Done ❑ Type of Pump N/A H.P. WA State Work Done N/A _ Well Destruction I J Well Diameter 411 Sealing Material) 7-3' Bentonite Seal % Bentonite Groi it Depth Filler Material E&WI#3 sand below Bentonite Seal. _ TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR/ADDITION 0 DESTRUCTION ❑ (No septic system permitted if public sewer is C, available within 200 feet.) P 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 fl Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Wait Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED [1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 " certify that in the performance f the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ca' rnia." The applic must call f e i ti Complete drawing on reverse side. Signed Title: Date: ">r FOR DEPARTMENT USE ONLY p Appli epted by / Date S17 Area Pit r Grout In action by TDat \ S / Final Inspection la _ Date A 1 i Comments: - t' - a OW Ir r ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manta 823-7104 ❑ 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'R'E'MITTED 'WH REC�EEIVVED BY �/ D]ATE{.� (y'�P•ERMIT'NO. . EH 13 24(REV .,..� `i I / ✓-a 7 EH 1428 ✓