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We APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRTtT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 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 18846 N Highway 99 City T pdi Lot Size +20 er-es— PM Owner's Name Goehring Meat Address same Phone 464 1 393 Contractor Clark Well Address 2024 E Charter License No371 560 Phon – TYPE OF WELL/PUMP: NEW WELLAZX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.+10 0 r PROP. LINE zC; FOUNDATION AGRICULTURE WELL OTHER WELL n_n__ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 2 0 Dia. of Well Casing 1 2 3 Z 4" ❑ Domestic/Private )fkGravel Pack ❑ Tracy Type of Casing St' - -I Specifications 8 gage } k-bfublic ❑ Other (I Delta Depth of Grout Seal 240 ' Type of Grout 9 Sack I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by others _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 — 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 ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 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 Di§trict. I--- 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: " the rforma a of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of Calif The applicant u c f all re gyred /s ction Complete drawing on reverse side. Signed X JJ /L Title: VP Clark Well Date: 17 Oct 1988 � FOR ,EPx�USE ONLY Application Accepted by -`' Date ��7—� Area Pit or Grout Inspection by Daty 1/0— Final Inspection by Date Additional Comments: ❑ Stk 466-6781 Lodi 369.362 ❑ Manteca 823-7104 O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEp MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH s.EH 114-263-211REV.tiKS) EH t 6)/ Ill.../// 1 to_'7 �.�� 0