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Y APPLICATION FOR PERMIT y !t SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) h District for a /or install the work herein described. This cation is Application compliancei made tothe San Joaquin Joaquin County Local Healt No.549 for sewage or'No�1862 forcwe111dpump and the Runes and Regulations of the Sant Joaquin made ! � [�•S_ �20 -04� i local Health f7istfict 370 oY.Ham* 5 @Hwy '1@t} �� [�. o Tracy Lot Size PM City Job Address j Owner's Name Jeffrey L. Brown Address 874 East Woodward. Avd. Phone (209)239-9406 Maggiora Bros. 595 Airport Blvd. Contractor DriTTiilg Inc. Address Watsonville CA 95076 License No. 249957 Phone TYPE OF WELL/PUMP: NEW WELL)V WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK None SEWER LINES None DISPOSAL FLD. Norte PROP. LINE FOUNDATION AGRICULTURE WELL X OTHER WELL PITS/SUMPS None INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 16rr Dia. of Well Ll Industrial El open Bottom ❑ Manteca Dia. of Well Excavation ll CiC r Trac Type of Casing Steel Specifications ' `N ❑ Domestic Private n Gravel Pack Y Type 10 SdGk ['l Public ❑ Other I ❑ Delta Depth of Grout Seal T e of Grout XIrrigation __Approx. Depth i I Eastern H P Surface Seal Installed by pntractor =4 State W one F Repair Work Done Ll Type of Pump Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INS;ALLATION [1 REPAIR/ADDITION l I DESTRUCTION I I afvailablerwi hine200 feet.) if public sewer i I Installation will serve: Residence i Commercial_ Other j Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: it No. Compartments SEPTIC TANK ❑ Type/Mfg Capac y Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number ,�,r; SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I hd that the work will be done in accordance with San Joaquin county ordinances, state laws, and ave prepared this application an rules and regulations of the San Joaquin Local Health Di$trict. 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: "1 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 IQs 11 re spe i S. Complete drawing on reverse side. Signed X ' Title: Contract administrator Date: 02-12--91 R DEPARTMENT USE ONLY / Data Area y' Application Accepted by jDate �— Final Inspection by Date 3� Pit or Grout Inspection by Additional Comments: ❑ Tracy 836.6385 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE CK RECEIVED!3Y DATE PERMIT"NO. INFO MOUNT DUE AMOUNT REMITTED �CAS�H(� + EH 13-24 IREY.i i A 51 A�� ©� l.J`''� 1 I �� i tH 1426 l�