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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA rrj { 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 and Regulations of the San Joaquin Local Health District. t; e Job Address 10351 X Jeaue Road City MantecaLot Size PM Owner's Name Erik Isbell _ Address 1803 West March Lane Phone 239-3794 Contractor's Name Martin Pump & Supply 7LiK se..No, 360»851 _ Phone 847-0394 t TYPE OF WELL/PUMP: NEW WELL X1 'WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ 4 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK None SEWER4 LINES None DISPOSAL FLD. None PROP. LINE. 1-51 ' FOUNDATION &5 �AGRIC l LTURE WELL Nom OTHER WELL--4-0-1— PITS/SUMPS -R4ne i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 6158 11 Domestic/Private lX Gravel Pack ❑ Tracy Type of Casing — Specifications j � I E-) Public E3 Other LJ Delta � Depth of Grout Seal Type of Grout Ren top i t e ❑ Irrigation --Approx. Depth ❑ Eastern urface Seal Installed by— Repair y Repair Work Done ElType of Pump H.P. ,— To State Work Done � I� Well Destruction ElWell Diameter Sealing Material (top 50') v E� Depth Filler Material {Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nb septic system permitted if public•sewer is available within 200 feet.)' ! e z. Installation will serve: Residence"—'..Commercial_ Other Number of living units: Number of bedrooms Character of sad to a depth of 3 feat: Water table depth 4 SEPTIC TANK ❑ Type/Mfg Capacity .f . Nol,Compartments �! PKG. TREATMENT PLT. F1Mef hod of Disposal ' w Distance to nearest: Well Foundation Property tine r LEACHING LINE ❑ No, & Length of lines t i /� Total length/'size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well - Foundation Property Line t 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 rules and regulations of the San Joaquin Local Health District. v ' I 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." �-�---- - -�' 4 t .I The applic t ust call for re ired inspections. Complete drawing on reverse side. Signed L Title: Date: FOR DEP T T USE ONLY Application Accepted by Date Area Pit or Grout Inspection by "ate rI� V Final Inspection by Date Additional Comments: El Stk 4664M1 ❑ Lodi 369-3621 O Manteca 823-7104 ElTracy 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. INFO CASH + EH 13.24(REV.101831 !J/tS EH 1426 - -