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II APPLICATION FOR PERMIT Ik I� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA ` t Telephone (209) 466-6781 I PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) j Ilcation is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app' made a compliance with San Joaquin County Ordinance l 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I ./ 9_ — C Ilh I' t� CityManteca Lot Size PM Job Address 1 1 139th St I! '� Phone (41 5) 357-840 Owner's Name Golden Grain Com arty Address I� 1401 Halyard, Ste. 140 Ph�(t� Contracto 16 372-47 0 �raundwater Techno),mays License No, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DE5TRUOTH ❑ ER c SO"—gaS sure y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ — 5 ft: --- SEWER LINf t J DISPOSAL FLD. ' — PROP. LINE -- DISTANCE TO NEAREST: SEPTIC TANK LINES 0 � 1 �� £ i FOUNDATION 5 f t. AGRICULTURE WELL — OTHER WELL *iIl!S/SUMPS ` TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE ��-- pia. of Well Casing ❑ Industrial�' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation none Specifications Type of Casing bentonite r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal 10, Type of Grout [-1 Public XXDther ❑ Delta �_hpprox. Depth I 1 Eastern Surface Seal Installed by I I Irrigation i State Work Done_ S Repair Work Done C1 Type of Pump H.P. Sealing Material (top 501 Well Destruction Cl Well Diameter Depth Filler Material (Below 501 k TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIAOD1710N I ! QE57RUGTION i I alvailablerwi within 200 feet.)c system if public sewer is Other Installation �/l Installation will serve: Residence_ Commercial r Number of living units: Number of bedrooms Water table depth Characters of sail to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Meth1i'Spn,Sa�e'. 1 PKG. TREATMENT PLT. ❑ it Distance to nearest: Well Foundation Property Lin n. Total length/size— 'I. engthlsize LEACHINGi LINE 171 No, & Length of lines ❑ Distance to nearest: Well Foundation Property Line rsi—`I FILTER BED F Size Number SEEPAGE PITS { I Depth SUMPS ❑ Distance oundation Property Line to nearest: Well 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 District. certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not I Home owner or licensed agent's signature cert I such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature employ any person in scertify that s the performan ce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- certifies the following: tion laws of California." The appliclant must call for all require inspections. Complete drawing on reverse side. 8/2/89 l 2 18,` _ *err?-�� TiVile. Geologist Date: Signed X��-�. FOR DEPARTMENT USE ONLY We_9____ AreaDate Application Accepted by Date Final I spection by Date Pit or Grout Inspection by � a� Additional Comments: O ElStk 466-6781 ❑ Lodi 369-3621 [D Manteca 823-7104 El Tracy 5-6385 s ApplicantF- Return all copies to: Environmental Health Environmental Health 1601 E. Hazalton Ave., P.O. Box 2009, CA 95201 ' FEE C RECEIVED BY DATE PERMIT NO. I� INFO AMOUNT DUE AMOUNT REMITTED l + Ell 13-24(REV.t�/rti5� �q3 'q�s� I EH 14-26 ,II