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,., APPLICATION FOR PERMIT ; SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address $617. ETCNEVERRY DR . LOT #$ City TRACY Lot size PM Owner's Name THOMAS BROWN Address P -0 - B 0 X 1308 Phone836-089 0 Contractor H E N N I N G S B R O S. Address 3525 P E L A N D A L E AVE. License No. 2 9 O$13 Phone 5!U_— 1 5 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f7 Domestic/Private Gravel Pack IJQ Tracy Type of Casing PVC {]n a Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 1� Type of Grout ❑ Irrigation OZApprox. Depth Ll Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material {below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r� available within 200 feet.) Ins on will server Residence— Commercial— Other Number of IN its: Number of bedrooms Character of soil to a dep 3 feet: Water table depth SEPTIC TANK ❑ Type/ Capacity No. Compartments (� PKG..TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wel Foundation Property Line w LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line {CC SEEPAGE PITS ❑ Depth Size Number C SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 must call for all required inspections. Complete drawing on r9verse side. Signed X��j`[VYUN–e,�i�A �� Title:V t t C," 1 Date: (e) " —W� FOR DEPARTMENT USE ONLY Application Accepted by Date /0 4�—_L�T Area Pit or Grout Inspection by Date oZl Final Inspection by Date 4 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63%i 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 CK CASH RECEIVED BY DATE PERMIT'NO. INFO + EH 1344(REV.i/s5) EH 1426 -V- $7-14