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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, a•a t ,"w # Job Address Valpico Road J mile E of Tracy Blvd. City Tracy Lot Size 34 acres PM Owner's Name Dale A. Cose Address 19E 6th St. , Tracy, CA 95376Phone 2825 Myrtle Street Contractor Spectrum Address Stockton, CA 95205 License No. C-57-512?,one 209 948-1345 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER R9 DISTANCE TO NEAREST: SEPTIC TANK >200' SEWER LINES >200' DISPOSAL FLD.>200'PROP. LINE _7M1 FOUNDATION200 r AGRICULTURE WELL X200 OTHER WELL 200' PITS/SUMPS `, 200' Q 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS bL� ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Od ❑ Domestic/Private ❑ Gravel Pack K) Tracy Type of Casing Specifications G F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout---,. y3 1 1 Irrigation -Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Imp 50') Sampling Depth Filler Material (Below 50') YPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRdADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will Residence_ Commercial_ Other y„ Number of living units: er of bedrooms Character of soil to a depth of 3 feet: Water table depth �J SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments fin( PKG. TREATMENT PLT. ❑ Method of Disposal% r� Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthlsize 6 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth `Size N Number - ' SUMPS D Distance to nearest: Well Foundation Property Line J DISPOSAL PONDS ❑ I hereby certify that f 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 Di§trict. 1�. I'\ 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 Califor iia." Contractor's hiring or sub-contracting signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I Nall employ persons subject to workman's compensa� tion laws of California." ka �a The applican u call for all requi ed inspections. Complete drawing on reverse side. Signed X Title: Date: ZS ._ D ENT USE ONLY. i. Application Accepted by Dated Area Pit or Grout Inspection by Date Final Inspection by� w Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO EH 13-24+ EH14-2BIREV.tiK51 - -70 �/ ^� Z