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MgCEIVEDAPPLICATION FOR PERMIT � SAN JOAQUIN LOCAL HEALTH bISTFTICt �pAYMEN'1` AUG 3 U 1991 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED APPLIED GEOSYSTEMS Telephone (209) 466-6761 r SACRAMENTO BRANCHPERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 6 1931 PE - S.AN JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVICES '. Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th�N11.1(IIOIdI��N1rb1LTTly,s�eppkn is +, made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules and Regulations of the San Joaquin ,< Local Health District. Job Address 125775 Patterson Pass Road city Tracy Let size 00 ft PM Owner's Name nRrn curl 1:S Co Address 2000 Alameda delos Pulgas Blvd Phone 415-971-246c) Contractor J-CON ExP10ratiOn Address 1690 Mosswood Dr. Yuba License No. 563305 Phone916-755-2225 TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION ❑ -7.5011 borl n9.0 8d PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTH% Wapor extraction 11J DISTANCE TO NEAREST: SEPTIC TANK "10-70 Ft SEWER LINES NZA DISPOSAL FLO. E PROP. LINE FOUNDATION N/A AGRICULTURE WELLN/A OTHER WELL PITS/SUMPS .N/A INTENDED USE TYPE OF WELL-- PROBLEM AREA .CONSTRUCTION_SPECIFICATIONS,. {B VappY extra ion We11) ,fig O Industrial ❑ Opal Bottom ❑Manteca Dia. of Well Excav8bbli ° 0 a. of Wall Casing 4 inch i I ❑ Domestic/Private ❑ Gravel Pack A Tracy Type of Casing M7C Srb 40 _- _ SPaCificalldne I.1 Public IX Other Sand packl Delta Depth of Grout Seal 1.1-2Jr, —�N Type of Grout CeDgen+- F, }ren On] I I Irrigation _.Approx. Depth 1 I Eastern Surface Seal Installed by -- Repair Work Done ❑ Type of Pump L H.P. State Work Done _ Well Destruction ❑ Well Diameter 4 i nGh_ Sealing Material (top 50'1 Vapor Extraction Depth 50 Ff Filler Material (Below 601 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system m permitted if public sewer is availabInstallation will serve: Residence_ Commercial ,Other Number of living units: _ Number of bedrooms 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmelitst Method of PKG. TREATMENT PLL El Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines =:Total length/size' `� R 1, FILTER BED ❑ Distance to nearest: Well Foyndatfon Property Line ^.nl)NTY SI RVICES , a -- Number4 •n 101 SEEPAGE PITS I I Depth __ _ -9ize SUMPS 'Ll Distance to nearest: Well _— Foundation Property ma ,R k DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done;in4kcurdance with San Joaquin county ordinances, elate laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: •'1 certify that in the perh;hpance of the work for which this permit is issued, I shag 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 following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The applicant mus for, lire uir spections. Complete drawing on rev�rs�si a. Signed % Title: n,-,�"�TTa,. r--��.,...:..t_-1 Date: AS7vn�k��__Lgg 1. - . OR DEPARTMENT USE ONLY • /}l Application Accepts y r q Date /0 / Arae 3`-'nJ� Pit tx Grout Inspection by Date P L/ Final Inspection by �r�`. Date Addhbnel Comments; r eirr rtCl ^ rn 0 ,dam `Sct C m Tracy Applicant Pate rn all copies sLodi oi: 369-3621 nv Environmental He❑I hjnteca Perrmit�ervi ea41601 E❑HazaRon TAve.,P.O. Box 2009, Stk., CA 9520 �ro� FEEA OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. INFO . EN 13-24(REV.I/As) FH 14