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APPLICATION FOR PERMIT ��u SAN JOAQUIN LOCAL HEALTH DISTRICT Q 1601 E. HAZELTON AVE., STOCKTON, CA ` Telephone (209) 466-6781 $ P Z 2 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENWONMENTAL HEALTH Rpb�o{jT SERVICES Application is hereby made to the San Joaquin local Health District for a permit to construct and/or install the work hetescnbed. 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 6608 E. Sarcrent Rd. city Lodi Lot Size PM Owner's Name Julia Rider Address 6608 E . Sargent Rd. Phone Contractor Goehrin Pum AddressP.O .BOX 113 Lockefordrise No. 309031 Phone 727-5548 I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIRXX OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ---FOUNDATIONLmL-L-- AGRICULTURE-WELL - — -OTHER-WELL �PITS/SUMPS` — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Cl Public 71 Other f-1 Delta Depth of Grout Seal Type of Grout i I Irrigation -Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done X1 Type of Pump Sub. H.P. 1 State Work ponebrt7L1 ht UD g p ._ code Q Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material I8elow 501 TYPE OF SEPTIC WORK: ,NEW INSTALLATION i'I REPAIRIADDITION I I DESTRUCTION l 1 (No septic system permitted it public sewer is available within 200 feet.) !� Installation will serve: Residence— Commercial_ Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ^T Water table depth r SEPTIC TANK Ll -Type/Mfg"" - Capacity - Na-Compartments PKG. TREATMENT PLT- ❑ t Method of Disposal Distance to nearest: Well Foundation -"''Property Line LEACHING LINE ❑ No. & Length of lines Total length/size P FILTER BED ❑ -Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number _L-V 7Distance to-nearest: Well - Foundation � Property Line DISPOSAL PONDS ❑- 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 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 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 ' The applicant mu t all r uired inspections. Complete drawing on reverse side. .Signed X Title: Bkpr• Date: 09/21/88 FOR DEPARTMENT USE ONLY Application Accepted by Date Area V Pit or Grout Inspection by Date Final Inspection by Date = 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 1 -24 tREV-i/x 61 f { EH 144-28 �7�