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.I 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 (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 pp Y 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. - T 300' 13 Job Address 24308 South Patterson Pass Road City Tracy Lot Size'-J&1 2` L.' PM Owner's Name Ira Matheny Address 1064 Woodland Ave Suite H Phone 57750 4 � Contractor's Name Martin Pum & Su 1 -'IJ AGse No.`� .v 360.= 5] "' '` Phot; --'—'-" p TYPE OF WELL/PUMP: NEW WELL 91 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION rJa SYSTEM REPAIR ❑ OT R,JW' . I DISTANCE TO NEAREST: SEPTIC TANK1�OU - SEWER LINES lO D DISPOSAL FLD166 2' PROP. LINE FOUNDATION AGRICULTURE WELL L-- OTHER WELL K t% PITS/SUMPSQ-0— 45 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSbSIS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _Dia. of Well Casing D9 Domestic/Private ® Gravel Pack ❑ Tracy Type of Casing Rt•aa1 Specifications c ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 501 Type of Grout ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by_ Repair Work Done O Type of Pump H.P. "State Work Done Well Destruction ❑ Well Diameter I Sealing Material (top 50:) A Depth d __....-_ _ Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTAL TION ❑ 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: 'f '_ _ Water table depth SEPTIC TANK ❑ Type/Mfg " + Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Di ea rest: Well Foundation Property Line n LEACHING LINE i❑ No. &_C -fh_of lines Total length/size t FILTER BED ❑ Distance ton crest: -Well10-30 R Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well F6undatl� Propefta Line DISPOSAL PONDS ❑ iii . I hereby certify that I have prepared this application and that th 'v�I be done in accordance with San Joaquin county ordinary s, state laws, and' rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following 'I cert) 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 woman's c pensation laws of California."Cor ractors hiring or sub-contracting signature' certifies the following:"I certify that in the performance of the wdrtc for rch this permit is issued, I shall employ persons subject to workman's compensa-' tion laws of Californi ." y The applican st call for all re aired ins Ions. Comp) t wing o `reverse.side. Signed -. F_ d :,19� Date: ANT USE ONLY v ! Application Accepted by w Date `~ Area 'Pit or Grout Inspection by Date Inspection by Date Additional Comments: . -- -�--�-- --__ --. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca823-7104 ❑ Tracy 835 6385`` h Applicant- Return all copies to:Environmental Health Permit/Services'1601 E. Hazelton Ave.,- P.O. Box 2009, Stk., CA 95201 FEE AMOUNT D AMOUNT REMITTED , OK RECEIVED BY DATE PERMIT'NO. f INFO ( H ( j ry EH 14-24 1REV.191931 '� t9� ! F - . Y_ 143' f C 43 cU