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} �- ' _ APPLICATION FOR PERMIT RECEIVED" SAN JOAQUIN LOCAL HEALTH DISTRICT OCT 2,3 1989 1601 E. HAZE; TON AVE., STOCKTON, CA �.f ,`�+ Telephone {209) 466-6781 RCNki� TAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FRT/Sa4RVfCIs (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 24575 N. Pearl Rd. City Lot Size 'PM Owner's Name JERRY SAYER Address 24575 N. Pearl Rd. Phone�J 17754 N. Hwy. 88 ContractorGoebrinQ Pump Address Lockeford License No. 309031._--___Phone727-5948 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION IX SYSTEM REPAIR ❑ OTHER ❑ V DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS '- INTENDED USE"'- TYPEtF-171EC0n "'PROBLEM AREA �-CONSTRUCTION--SPECiFIC-A-TIONSy----'-_`°-= ❑:Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ 1 1 Irrigation —Approx. Depth I ) Eastern Surface Seal Installed by _ 9—J Repair Work Done LJ Type of Pump —Cfl H,P. 2 State Work Done replaced Old pump —C Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 �' �J r TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION l { n I DESTRUCTION i-1 (No septic system permitted if public sewer is v l available within 200 feet.) :Installation will serve: Residence_ Commercial— Other l 1 ^� 'Number of living units: Number of bedrooms +: •+�` ;,: � ' Character of soil to a depth of 3 feet: ; ' Water table depth µs SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ j ' Method of Disposal Distance to nearest: Well Foundation i Property Line LEACHING LINE ❑ No. & Length of lines ' # Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size r Number , SUMPS ❑ Distance to nearest: Well r ' ""Foundation" Property Line DISPOSAL PONDS ❑ hereby certify-that I have prepared this application and that the-work will be done-in-accordanbe with San-Joaquin--county-ordinances,-state'lawsa ander=i0' rules and regulations of the San Joaquin Local Health Di"strict. ` Home owner or licensed agent's 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 sucher as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I y that in the performance of the work for which tFiis•permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Californi The applicant mu all r uired inspections. Complete drawing on reverse side. k Signed X Title: Bk r. Date: 10/20/89 µ, OR DEPARTMENT USE ONLY / Application Accepted by Date Area �r ? Pit or Grout Inspection by ate Final Inspection by :7—_� 1" Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M5 Applicant - Returh all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' .1 FEEINFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. I +,EH 1324(NEV.t i w 5) 3-y Gh p-2-5- C� 7 y 3 EH 1t-28