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APPLICATION FOR PER�NiT SAN JOAQUiN LOCAL �=EALTH D STRICT 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 Z 1-7,9 r/ -tki s-kp Subdivision Name Owner's Name PAREDES RANCH Address 139 Brunning, Rio Vista, 94,571 Contractor's Name Goehring 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 IJ Industrial U Open Bottom []Manteca Dia. of Well Excavation U Domestic/Private F-�Gravel Pack Tracy Dia. of Well Casing Public Other Delta Type of Casing Lj Irrigation Approx. [] Eastern Depth Specifications ❑Cathodic Protection Depth of Grout Seal 17 Geophysical Type of Grout Other Surface Seal Installed by Repair Work Done IN Type of Pump Sub. H.P. 3 State Work Done repair elec. short in Wel Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') CA TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 (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 SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total length/size ' FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number V► SUMPS ❑ 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 `gent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, all not employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hi r!sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit i I 11 employ persons subject to workman's compensation laws of California." The applican 1 Ll l r ired inspections. Complete drawing on reverse side. Bk r. kA Signed X Title: p Date: 0 3 FOR,IDEPARTME T USE LY Application Accepted by Area ❑ Stk 466-6781 Additional Comments: J?f Lodi 369-3621 Pit or Grout Inspection by Date 0 Manteca 823-7104 Final Inspection by Date r L7 Tracy 835-6385 Applicant - Return all copies to: 6,41ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. INFO �7- 10/82 500 EH 13-24 REV. 10/82 14-26