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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA +� Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE /SSU OCT 1989 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and thefffl1W9!nd W_01"ti6Rs of the San Joaquin Local Health District. Job Address 8710 E. Collier Rd. City Lot Size PM f - Owner's Name I]l1ANE MARTIN _ Address Phone - 17754 N. Hwy. 88 Contractor GOEHRING PUMP Address Loekeford, Ca. License No.309031 Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION )CK SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1`1 Public ❑ Other Cl Delta Depth of Grout Seal' Type of Grout i - I I Irrigation --Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Sub__.__-_ H.P. I t _ State Work Done Well Destruction -E] Well'DiameieF"---- Sealing-Material'Itop 501" - -- .Depth- - �--Filler.MatenA_L(Below SO'-),, -. .. TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION 1 .1 DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) I Installation will serve: Residence_ Commercial_ Other O Number of living units: Number of bedrooms - Character of soil to a depth of 3 feet: -f J r 3 f_ Wa`ier table depth SEPTIC TANK ❑ Type/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ �' >--- r Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wel! Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line _ - .,_DISPOSAL-PONDS ❑..". . :.._: -: :. -� -=.'-�'.'- �.. .- -r"...'.��-?..:cr:�—.--$.._. mow^: � _ _•=�-,....� - -� Fc,arn„. war,rk 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' 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 er as.to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"! rt' 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 Caiifornia The applicant must I !I a ired inspections. Complete drawing on reverse side. i 9 Signed X Title: k r. Date: . 10/25/89 F DEPARTMENT USE ONLY j Application Accepted by � Date ✓� Area Pit or Grout Inspection by Date Final Inspection by Date . Additional Comments: ❑ Stk 466-678t ❑ 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 gQ01 1 /FEEO AMOUNT DUE AMOUNT.REMITTED CASH CK k RECEIVED BY DATE PERMIT`NO. { f +.EH 1 -24 1 pEV,1/H 5) I� EH 1 4-28 �/ '