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i APPLICATION FOR PERMIT r: ' L C ; SAN JOAQUIN LOCAL HEALTH DISTRICT � I 1601 E. HAZE.TON AVE., STOCKTON, CA S U L 15 T991 Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 Sari 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. Y Job Address 17093 Trethpway Rd City I Cul i Lot Size PM Owner's Name FRANK TERRA Address 17093 TrethpwAYAIJ Phone P.O. Box 113 Contractor Goehring Pump --Address 17754 N. Hwy. 88 Lk . License No. 309031 Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 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 I`i Public f 1 Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump SubmerS1bae. I State Work Done 1HP Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler.Material (Below-50') — TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRlADDITION I) 6ESTRUCTION I I fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other t '1 .�- Number of living units: Number of bedrooms --�- LJ1 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.lo-nearest:. .Well-------Foundation- -- -Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ - I hereby cert that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Paws;an rules and regulations of the an Joaquin Local Health District. Home owner or licensed a is 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 sig er as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin ify t t in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cakifor The applicant m fl u'red i ctions. Complete drawing on reverse side. Signed X Title: Bkpa^. Date: 07 III FO DEPARTMENT USE ONLY //.� Application Accepted by Date 7 "' Area Pit or Grout Inspection by Date Final Inspection by77�p4 ?2�a_-zoa _dDateZ Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Trary 835-6385 j Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CKCASH RECEIVED BY DATE PERMIT NO. + EH 13-241NEV.4/115) P - ,{4!` f 1819 EH 1128