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0 APPLICATION FOR PERMIT V P41"MENT SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED 1601 E. HAZELTON AVE., STOCKTON, CA OCT ' (� '�90 Telephone (209) 466-6781 SAN JOA PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC QUIN COUNTY ENVIRONMEN HEALTH SERVICES (Complete in Triplicate) AL HEALTH DIVISION Application is hereby made to a 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 aquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 00 Job Address W. 6th Street City Tracy Lot Size PM owns ' ame CiK o2 TT TrOacck Address 520 Tracy B1., Tracy, CA 95376 phone 209/836-4420 3342 Brennans Rd. , Contractor Ho to Dr n Address Loomis, CA License No. 401530 Phone916/65E-4640 TYPE OF WEL UMP: NEW WELL C* WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE T REST: SEPTISEWER LINES DISPOSAL FLD. PROP. LINE F DATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF W L PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open om ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing 411 ❑ Domestic/Private Pack racy Type of Casing 411 SCh 40 PVC Specifications K/R[ibl/c/monitor X Other SandPack Depth of Grout Seal Type of Grout cement ❑ Irrigation 25—'Approx. D ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of P 411 H.P. It State Work Done Well Destruction ❑ Well Dia eter 25 , 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 available within 200 feet.) 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 ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Found' Property Line LEACHING LINE ❑ No. & Length of linesT tal length/size FILTER BED ❑ Distance to nearest: Well Foundation roperty Line SEEPAGE PITS ❑ Depth Size ber SUMPS ❑ Distance to nearest: Well Foundation Pr Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordan oa 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 th or r whi is permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California.' ontra 's hiring o ub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall em per subjec to workman's compensa- tion laws of California." The applicant ust I for all required inspections. Complete drawing on reverse side. Signed Title; C.E.G. 1136 10/2/90 FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area Pit or Grout Inspection by Date Final Inspection by Date 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 CK RECEIVED BY DATE PER N0. INFO CASH + EH 1320 1REV.1/N 5) EH 14-26