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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT x 1601 E. HAZE T ON AVE., STOCKTON, CA D f•d °� �� Telephone (209) 466-6781 11J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG (Complete in Triplicate) ��pp��p�� 7�-�p�I {{��FF�� {u� Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the v��t��r�rf1'tltssc�itldC7 TMkTk`ation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the RuIe+"bUVbERVl1USan Joaquin Local Health District. Job Address 18846 N. Hwy. 99 , City Lodi Lot Size PM owner's Name GOEHRING MEAT Address P 0 Box 147 , Lodi , Ca . Phone Contractor Goehring Pump Address P.0 .Box 113 , LOCkef(D-tdse No, 309031 Phone_ 7 2 7-5-548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 1x1 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 f"1 Public ❑ Other F] Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth 1 1 Eastern Surface Seal Installed by _ Repair Work Done LX Type of Pump turblrie H.P. 20 State Work Done _repaired bowl Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (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 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L] Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1-1 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. 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 followin "I ertify 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 Califo The applicant Im or required inspections. Complete drawing on reverse side. Signed X Tide: Bkpr.. Date: 08/11/88 /FOR DEPARTMENT USE ONLY Application Accepted by �� Date _ �% Area' Q� 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH Q/,p � EH 13-24(REV.Ii N5i � 3� � r ,{J✓°�" � I � �� V" �rrq EH 14-26