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4A Y` - �, APPLICATION FOR PERMIT ,k SAN JOAOUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED EP 2 19$8 (Complete in Triplicate) Application is heieb made to the San Joaquin Local Health District for a permit to construct and/of in $ j s application is PP y �l�r 3f made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump n ICES he San Joaquin Local Health District, Simpson Paper-Co. °End of Stockton St. Ripon See Map PM Job Address City Lot Size J�. Owner's Name S :mpscm P,-O--r Co_ Address P_n BOX 757 Rip= CA Phone (209)599-4241 Contractor Lawrence &h Assoc. Address 1730 South St. Redding License No. 334700 PhorfJ916) 244-97133 TYPE OF WELLIPUMP: �P 'NEW WELL EX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Unk DISPOSAL FLD. 1 500' PROP. LINE FOUNDATION 10' AGRICULTURE WELL Unk OTHER WELL SDD r PITS/SUMPS Unk INTENDED USE TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation All Dia. of Well Casing N/A ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Total De th Concrete * Public Other [� Delta Depth of Grout Seal __ p Type of Grout f I Irrigation �LApprox. Depth l I Eastern Surface Sedl installed by Repair Work Done ❑ Type of Pump N/A H.P. N/A State Work Done Well Destruction EX WeiI Diameter g° Sealing Material Itop 501 Test BoriDa Depth Filler Material Melow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTION 1 1 (No septic system permitted if public sewer is :iI. available within 200 feet.i Installation will serve: Residence_ Commercial— Other Number of living units: °il Number of bedrooms Character of soil to a depthli 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I� Method of Disposal Distance to nearest: Well Foundation Property.Line r n I� V LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED ❑ Distance to nearest: Well Foundation Property Line :F SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ ``Distance to nearest: Well Foundation _ Property Line { DISPOSAL PONDS ❑ .II I hereby certify that I have prefpared 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 (P 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 certify 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." ,I The applicant t call for all required inspec'ons. Complete drawing on reverse side. See Attached Geologist 9/12/88 Signed X Title: Date: if A If - FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final 1,,,e ti, by Date/ i� Additional Comments: ❑ Stk 466-6781 ❑ Lodi 36973621 V ElManteca 823-7104 ❑ facy 5 Applicant- Return all copies dta: Environmental Health Permit/Services 1601 E. Hazelton e., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. tNFO AS ♦.EH 13-24MEV.1/951 `J j' Urb EH 14-2e