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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) etv\ Y—'; 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 aril Regulations of tlife San Joaquin Local Health District.&JAA9 5-37 /rg Y /3 7 (-2 Job Address Next To 2086 7 South X City Tracy IIIIMAXXX Hansen Lot Size 5 Arces PM Owner's Name Mr Tony Mackensie Address 20857 South Hansen Phone 835-8154 TYPE OF WELL/PUMP: = - NEW WELL CC Contractor's Name Martin Pump & Supply License No.360-851 Phone 847-0394' DISTANCE TO NEAREST: SEPTIC TANK PUMP INSTALLATION 211 FOUNDATION SEWER LINES DISPOSAL FLD. PROP. LINE AGRICULTURE WELL _ OTHER WELL PITS/SUMPS WELL REPLACEMENT D DESTRUCTION 0 SYSTEM REPAIR 0 OTHER ID INTENDED USE TYPE OF WELL ID Tracy Type of Casing Steel Delta Depth of Grout Seal CI Eastern Surface Seal Installed by State Work Done TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is available within 200 feet.) E Industrial XI Domestic/Private El Public El Irrigation Repair Work Done Well Destruction El Open Bottom C.1 Gravel Pack 0 Other _Approx. Depth Type of Pump Well Diameter Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS Manteca Die. of Well Excavation 1P H.P. Sealing Material (top 50') Filler Material (Below SO') 50' Dia. of Well Casing 6 5/8 Specifications Type of Grout b_et11Q11.L_k__. t Other Installation will serve: Residence _ Commercial _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK CI Type/Mfg PKG. TREATMENT PLT. 0 Distance to nearest: Well Method of Disposal Foundation Property Line Water table depth No. Compartments rt_F- 3 0„ Capacity LEACHING LINE C No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line L 4 ‘.SEEPAGE PITS 0 Depth' A Size Number .. _ _ ' 'SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lair:is, and rules and regulations of the Sari 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 iisued, I shall emploi, persons subject to workman's compensa- tion laws of California." . 1, oe The applicant rn all for all require inspecti rm. Complete drawing on reverse side. Title: Signed Date: 0 7 Application Accepted by FOR DEPARTMENT USE ONLY Date Pit or Grout Inspection by Date Final Inspection by Area Date 740 '-AdditiOnal Comments: littk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 EH EH 13-24 MEV. toirce EH 1426 FEE INFO AMOUNT DUE AMOUNT REMITTED Ca CASH RECEIVED BY DATE PERMIT-NO. Fil"-7 1+121 WO 8-1-0A-ti Ft-V.-100(.0 I, V - 101'5 i