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• s . yam. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA k 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 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules anp Regulations of tlfe San Joaquin ' Local Health District/s em rr 37 /,r 9- Y ./'3 -7 v Job Address Next To 208#7 South XWERNNIU Hansen City Tracy Lot Size 5 Arces PM Owner's Name Mr Tony Mackensie Address 20851 South Hansen. Phone 835-8154 ' Contractor's Name Martin Pump & Su 1 License No. 360-851 Phone 847-•039+L TYPE OF WELL/PUMP: - - NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ixi SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.'LINE l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing l] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing $ Specifications C7 Public ❑ Other ❑ Delta Depth of Grout Seal 501 Type of Grout Bentonite ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') { Depth Filler Material (Below 501 F 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 C SEPTIC TANK ❑ Type/Mfg [ +'� n Capacity No. Compartments E PKG. TREATMENT PLT. C1 Method of Disposal S Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line +i SEEPAGE PITS . ❑ Depth', Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 i 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 m all for all require inspecti ns. Complete drawing on reverse side. Signed Titles �� r- /Vl��L�• Date: FOR DEPARTMENT USE ONLY �y Application Accepted by e4Date �d Area Q Pit or Grout Inspection by Date Final Inspection by Date //B `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 RECEIVED BY DATE PERMIT'NO. y INFO �CASH �{ + EH 13-24 IREV.10/83) EH 14.26