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VAPPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 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 City Lot Size PM E i Owner's Name JON MENOUGH Address 2!'355 1V Rr t 1 1 A RC1- _ Phone k Contractor GOEHRTNC PUMP Address License No._-M9031 Phone727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIRX® OTHER ❑ ,DISTANCE TO,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i ��" �'""-'!INTENDED USEr'�`'�TYPE-O F'WELL"�'�'PROB�ENI li'RE=A�"'CONSTRlfET1ON-'SPECIFfCAI"IDMS"�'��-�`�-�"~-=-�"-�^-�• ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i FI Public ❑ Other f_1 Delta = Depth of Grout Seal Type of Grout _ 'r I i Irrigation +o� --Approx. Depth I I Eastern Surface Seal installed by _ _ Repair Work Done XJ Type of Pump SIlb H.P. 5 _'� State Work Done rPll)ce al CI 1)ijmTWlth HP Well Destruction El Well Diameter Sealing Material' Itop 501 Depth Fi]ler'Material IBelow 50'1 q TYPE OF SEPTIC WORK: NEW INSTALLATION i] REPAIR/ADDITION ! I DESTRUCTION I I (No septic system permitted if public sewer is �f .� available within 200 feet.) vl Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms L-„___, Character of soil to a depth of 3 feet: - - Water table depth j SEPTIC TANK ❑ Type/Mfg ~ Capacity No. Compartments i j PKG. TREATMENT FLT. ❑ _ Method of Disposal I Distance to nearest: Well _ `Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED - ❑ Distance to nearest: Welt Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L-! Distance to nearest: -Well f=oundation Property Line DISPOSAL PONDS ❑ j i-hereby'certify"that I have-prepared-this applicatidri arid-that--the ovork-Will-be'done in accordg-nce-with-SanJi)54uii cbuhty`ordinances;stateId-W-6 and�'""r rules and regulations of the San Joaquin Local Health District- Home owner or licensed agen 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 ner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: " 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 Califor ' i The applicant mu fA. allfired inspections. Complete drawing on reverse side. Signed X 0 Title: Rknr_ Date: _ 06/29/89 h FOR DEPARTMENT USE ONLY i Application Accepted by Date , Arae • - _ Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: ❑ Stk 466-6781 - ❑ 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH +.EH 13-24{REV.1/A 51 - EH 14-2e