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APPLICATION FOR PERMIT '`" SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZE; TON AVE., STOCKTON, CA JUL jgg Telephone {209} 466-6781 PERMIT EXPIRES TYEAR 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 l 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 IR700 N_ Hwy_ 88 city Lockpfarri Lot Size PM • r Owner's Name __-LAY I S RFSTAIIRANT Address _18700 N_ 'Hwy_ lift I_ockefOrd — Phone 17754 N. Hwy. 88 Contractor GOFHRING-RUMP Address License No,309031 Phone-727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ t SYSTEM REPAIRXIXX OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINT FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDFD USE TY—P E76F-WELL "PROBLEMAREA CONSTIRbC7IOIV'SPECIFICATIONS"-``�' ``—y— -" --�-- ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public C1 Other L] Delta Depth of Grout Seal Type of Grout I Irrigation . _.-Approx.,Depth I I Eastern Surface Seal installed by Repair Work Done A Type of Pump S,ib, H.P. 3 __ State Work Done rQn 1 a C P[1 O 1 d it with Well Destruction El Well Diameter Sealing Material (top 50'I 3HP sub, _ iI Depth Filler Material (Below 50.1 C�1 TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION f I DESTRUCTION I 1 (No septic system permitted if public sewer is 0 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: f Water table depth SEPTIC TANK ❑ Type/Mfg -Capacity No. Compartments:,.,-at. ♦F PKG. TREATMENT PLT. O w ' Method of Disposal Distance to nearest: Well "^'—z Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size jUE 24 19,3 FILTER BED I❑ Distance to nearest: Well u Foundation Property Line r-`,! `iROINIMENTAI_F#EPEF,` SEEPAGE PITS_ 1 I Depth Size Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 agen' ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 1 employ any person in such a er as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: " rti 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 Californi The applicant mus I re ed inspections. Complete drawing on reverse side. Signed X Title: Date: 07/20/89 DEPARTMENT USE ONLY _ Application Accepted by .(�" Date 7~d Area Pit or Grout Inspection by ate Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 FEE CK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 7 I +.EH 1 (REV.1/K51 � r EH 1l-4-29 - r