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APPLICATION FOR PERMIT READY FOR SAN JOAQUIN LOCAL HEALTH DISTRICT INSPECTION 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT- NO: Telephone (209) 466-6781 DATE ISSUED 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. Job Address 13683 N. Hwy. 88 Subdivision Name Owner's Name E. Fr Son Dair Address 13683 N. Hyy. 88 Lodi Phone 4 Contractor's Name Goeh lng Pump License No. 309031 Phone 727-5548 ' TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT [] DESTRUCTION ❑ PUMP INSTALLATION 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 ❑ IndustrialOpen Bottom ❑ Manteca Dia. of Well Excavation 14" Domestic/Private ❑ Gravel Pack ❑Tracy Oia. of W61 V Cas`ing ❑ Public ❑ Other [] Delta T of Casing Steel Irrigation Approx. L] Eastern F-1CathodicProtection Depth Specifications Depth of Grout Seal 50 ft. -- 1-1 Geophysical Type of Grout 9 $aCk 111iX Other Surface Seal Installed b Go ehr in P miA y g u � Repair Work Done Q Type of Pump sub. H.P. 7 State Work Done W Well Destruction U Well Diameter Sealing Material (top,50,') _ Depth 290 f t. Filler Material (Below 50') ti TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION j, (No septic tank or seepage pit permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms -- °'Lot size Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal __ OJ SEWAGE SYSTEM Distance to nearest: Well ZT�66ndati.on s Property Line ./1 DESTRUCTION ❑ 00 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well, - Foundatbn Property Line SEEPAGE PITS F1 Depth Size Number SUMPS Distance to nearest: --Well_ _ Foundation Property Line DISPOSAL PONDS ❑� I hereby certify that 1 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�71 ent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, not employ any person in such manner as to become subject to workmant compensation laws of California." Contractor's 'h ub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit i , I s all employ persons subject to workman's compensation laws of California." The applica t 1 r all required inspections. Compl'et'e drawing on reverse side. Signed Xtitles Bkpr.. Date: 12/16/86 P TMENT, ONLY A ',Application Accepted by k Area ❑ Stk 466-6781 Additional-.Comments: , . , ' i �odi 3693621 Pit or Grout Inspection Date /Z ❑ Manteca 823-7104 Final Inspection by Date ❑ Tracy 835-6385 Applicant - Return all copies t . onmental Health Permit/Services 1601 aze ton Ave., P.O. Box 2009, Stk., CA 95201 [FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO EH 13-24 REV. 10/82 10/82 500 14-26