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• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DIST ICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone (2091466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EP 2 11988 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in��/ [( j�ff�Q s application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump 3nd tFpjyij M1 f I�tE JT1he San Joaquin Local Health District. YYY�tKKMM C. Simpson Paper Co. End of Stockton St. City Ripon Let Size See Map PM Job Address Owner's Name C+]RIpC[tn Paper Co. Address P n BOX 757_R'Pon CA Phone (209)599-4241 Lawrence & Assoc. Address 1730 South St. Reddingticense No. 334700 Phon1916) 244-97 Contractor TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Unk DISPOSAL FLD. 15110' PROP. LINE ILIX FOUNDATION 103 AGRICULTURE WELL Unk OTHER WELL g00r PITS/SUMPS UDk INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation 1' Dia. of Well Casing N/A ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing N A Specifications FI Public N Other fl Delta Depth of Grout Seal Total Depth Type of Grout Concrete _- I I Irrigation 141 Approx. Depth I f Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump N/A H P N/A State Work Done_ Well Destruction EX Well Diameter 811 Sealing Material (top 50') `fest Boring Depth la! Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION I-I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size — Number SUMPS LI 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 Dlhtrict. 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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I cenify 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 California." - -. ;--1 V/ i LJ The applicant t call for all required inspec ons. Complete drawing on reverse side. See Attach Signed X r .� Title: Geologist � �t�/1 88 FOR DEPARTMENT USE ONLY Application Accepted by Date Area 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 INF FEEO CASH AMOUNT DUE AMOUNT REMITTED CK RECEIVED eV DATE PERMIT'NO. . EH 13-7A IREV.1/est EH 1479