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APPLICATION FOR PERMIT �? j I Return Permit to SAN JOAQUIN LOCAL HEALTH DISTRICT PERMIT N0. O 3 - Oj ty of Lodi 1601 ET. elephoneN(209),466-6781N, CA DATE ISSUED 16- 3-7-33 P.O. BO X 320 Lodi , CA 952+1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) to ATTN: Mark Lindseth rein Application is hereb1made o oishee San made iJoaquin Loc co wHeaith lth District Joaquin for a PerdinancecNo. 549tfor dsewage sorlNo. 18621'forewell/pump described. This appi and the Rules and Regulations of the San Joaquin Local Health District. - Subdivision Name ��a 1775 Job Address 6161 E H i hwa 1 Phone ak9z .-__— Owner's Name Pau] Gerdes Address P.O. Bo 8 L f Phone License No. 2 Contractor's Name Goehring PUMP �k 1 Q WELL REPLACEMENT [� DESTRUCTION { TYPE OF WI LLIPUMP WORK: NEW WELL SYSTEM REPAIR OTHER I er Well Abandonment PUMP INSTALLATION [j DISPOSAL FLD. PROP. LINE — DISTANCE To NEAREST: SEPTIC TANK . SEWER LINES i�pITS/SUMPS i AGRICULTURE WELL _ OTHER WELL .20W__-PITS/SUMPS FOUNDATION �\ -�J CONSTRUCTION SPECIFICATIONS _INTENDED USE TYPE_ OF �IELL PROBLEM AREA j] Industrial 3 Open Bottom ❑Manteca Dia. of Well Excavation \ Domestic/Private F-1 Gravel Pack ❑Tracy Dia. of Well Casing Public other E]Delta Type of Casing j U Irrigation 510 t Approx. M Eastern Specifications Te s t F-If Cathodic Protection Depth Depth of Grout Seal k LJ Geophysical Type of Grout Other t Surface Seal Installed by Type of Pum H.P. State Work Done Dr i 1 1 ed for sand water Sam 1 es Repair Work Done ❑ yP p Well Destruction U Well Diameter Sealing Material (top 50') Depth Filler Material (Below 501 f d if i TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITIDN ❑ (No septic tank or seepage p,availab}eewithinu200cfeet} is k Installation will serve: Residence Commercial Other F Number of bedrooms Lot size �T� Number of living units: Water table depth Character of soil to a depth of 3 feet: No. Compartments 1-j SEPTIC-TANK Type/Mfg Capacity � k Capacity Method of Disposal PKG. TREATMENT PLT. [] Type/Mfg Property Line Distance to nearest: Well Foundation . —�— LEACHING LINE U No. & Length of lines Total length/size i Line FILTER BED [] Distance to nearest: Well Foundation — Property ------ f SEEPAGE PITS t] Depth _ Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C4 y 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 District. which this Home owner or licensed agent's signature certifies the sucfollowing: manner as to becomeysubjectthatntohworkman perforcompensationwlawsfof California." ! permit is issued, I shall not employ any person in 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 compensation laws of California." The a t must call for al eq ired pections. Complete dr wing on reverse side. Date: O p Signed X _ Title: r.r: /y_� FOR DEPARTMENT USE ONLY Stk 466-6781 Application Accepted by Area � � .� Lodi 369-3621 Additional Comments: Manteca 823-7104 Pit or Grout Inspection Date Date (,� Tracy 835-6385 Fina} Inspection by Applicant Return all copies to: Envi onmental Health Permit/Services 1601 E. azeltcn Ave., P.O. Box 2009, Stk„ CA 95201 [FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. O 10/82 500 EH 13-24 REV, 10/82 14-26 -