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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1 E. HAZE T ON AVE., STOCKTON, CA 160 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUE QC- 12 1988 (Complete in Triplicate) �., �F> ! Nu,v 1? I„+1�i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th vr,� fdea�Vpj Egrhis application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and.the Rules and" egulations of the San Joaquin Local Health District. Job Address 144885 . Collier Rd. City Lot Size PM Owner's Name MERV KIRK Address 14488 E." Collier Rd. Phone Acampo Contractor Goehrin I�J'P=p Address1775 Lkfqlicense No. 309031 Phone — TYPE OF WELL/PUMP: 11" NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR EK OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATIONS AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE jTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑I�Open Bottom ❑ Manteca Dia. of Well Excavation " Dia. of Well Casing ❑ Domestic/Private D:Gravel Pack ❑ Tracy Type of Casing Specifications FI PublicI Other Cl Delta Depth of Grout Seal " Type of Grout — S { 1 Irrigation 1 _Appfox. Depth I-1 Eastern Surface Seal Installed by Repair Work Done 9 Type of Pump SubH.P. 3 State Work Done � reDQ Well Destruction ❑ I411 Diameter Sealing.Material (top 50') Dlepth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION L I DESTRUCTION l I Wo septic system permitted if public sewer is r+1 available within 200 feet.) t Installation will serve: Residence_ Commercial_ Other Number of living units: -Number of bedrooms -w- ' r- �' ' Water table depth Character bf soil-to,.a depth of 3 feet: SEPTIC TANK ❑ f Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. El i! Method of Disposal y Distance to nearest: We11 Foundation. Property Line LEACHING LINE ❑ No.•& length of lines ' r _ 1 Total length/size FILTER BED ❑ " Distance,to'nearest Well 'Foundation Property Line , SEEPAGE PITS I"I . Depth Size Number w k SUMPS ,' Distance to nearest: . Well _ Foundation Property Line ❑ ` DISPOSAL PONDS ❑ 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 su manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: ' eAify 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 applicant f r 11 required inspections. Complete drawing on reverse side, i Signed X Title: Bkpr. _"Date: 10/11/88 FOR DEPARTMENT USE ONLY Application Accepted by Date Area v Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copi.,,to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO � O a"EH 13-24 1REV.t/n 51 EH 14.261��