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•' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEI`TON 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 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_ 1 t^7 r7 1 4U esarcf job Address 10906 Wt Larch Road City � Lot Size PM Owner's Name Ira Matheny 1 Address 1064 Woodland Ave Suite H Phone 577-5014 Contractor's Name Martin Pump & Supply TL�Lqnse' No.' '360=851 Phone 847-0394 TYPE OF WELL/PUMP: NEW WELL "% ,�WEWREPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATI 2 SYSTEM REPAIR ❑ OTHTR ❑ DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES ��L DISPOSAL FLD,,Is�7T PROP. LINE FOUNDATION ..._— AGRICULTURE WELL&A2f_ OTHER WELL` 1 � PITS/SUMPSIV-We. INTENDED USE TYPE OF WELL , PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom , ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ® Domestic/ Private [9 Gravel Pack _}r ❑ Tracy Type of Casing Steck Specifications ❑ Public ❑ Other i] Delta _Depth of Grout Seal 501 Type of Grout S ❑ Irrigation --4pprox.'Depth '❑ Eastern -.Surface Seal Installed by Repair Work Done El Type of Pump 1 N.P. State .Work Done Well Destruction ❑ Well Diameter Sealing.,Material (top 501 Depth h Filler -Material (Below 501 ; TYPE OF SEPTIC WORK: NEW INSTALLA1r-,ION_0 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: I Water table depth �0 SEPTIC TANK ❑ Type/Mfg{ Capacity No. Compartments PKG. TREATMENT PLT.r❑ _' Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE -❑ No. & Length of lines Total length/size FILTER SED -✓.❑ Distance to nearest:. Well Foundation Property Line SEEPAGE PITS ❑ Depth r Size'- Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E_ S_ 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. 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 corppensation 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 Calif _ � . '. •, + The apptic • t m st call for all required in tions. Complete drawing on reverse side. i Signed ?Ca -ATitle: ^�� j= i Date:, - i , cf FOR DEPARTMENT USE ONLY Appl'icatiG'on Accepte"y Date Area Pit or Grout Inspection• by Date 4[ Final Inspection by Date Additional Comments: t' ElStk 466-6781 1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Enviroiimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 + EH 13-24IREV. 1018:1) EH 14-28 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 1°,A M w$iE