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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 7 js r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) DEC Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or inst II the rk �ibbd. Wication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump a .'les f, he San Joaquin Local Health District. \ l Job Address 16777 Howland Road l City Lathrop Lot Size PM Owner's Name J. R. Simplot Company Address P.O. Box 198, Lathrop CA 95330 Phone (209) 858-2511 Moorman's 2120 Wilcox Road __.J Contractor Water Systems Address Stockton, CA 95205 License No. 468816 Phone 209/931-321 —J 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 L r-1 Public C1 Other F1 Delta Depth of Grout Seal Type of Grout /W I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pum — � Stat Work Done _ v ANTA AI Well Destruction L3 Well Diameter �y --- lie4-5rng Mata* (top 50'):# �� +D 5V 1 -r Depth/ 19 r r Filler Material (Below 51T1 (� c( � It1 r CA /r �t/r/.v 'Qv7jr TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 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. El 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 Ll 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 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 following: "I certify 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 California." The app3�x te drawing on reverse side. Signed Title: Environmental Technician Date: 12/11/89 FOR DEPARTMENT USE ONLY Application Accepted by Date J Area Pit or Grout Inspection by Date - / Final�Inspection by�� Date,/ &Additional Comments: lgll/6 ��/►��'/ AJ AO ,7 4, ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 5 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 K RECEIVED BY DATE PERMIT'NO. INFO C H G p +.EH14-283-24(REV.1/9 sl 0 1 Q -70-00 3oqlJ c h d�—.7c,0 p EH 1 � -` ,`-J�•