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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �� sG� <br /> ■ 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> \ <br /> (Complete in Triplicate) �;��,��• <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Tk application is <br /> 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 <br /> Local Health District. <br /> r' <br /> Job Address 7782 E• Harney Ln. City Lot Size PM <br /> r <br /> Owner's Name —HM '& R RANCH Address 7782 E. Harney Ln. Phone <br /> Contractor GOEHRTNG PUMP i Address X7754 N, H nse No. S 30903FIone 727-554 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRXX OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OP~WELL ISROBLEIi+I'ARE4 C�)fVSTRUCTION`SPECIFiCPiTI01VS-'� `` -� _ - _ --_i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> Ll Domestic/Private ❑ Gravel Pack © Tracy Type of Casing Specifications <br /> 171 Public f] Other 0 Delta Depth of Grout Seal Type of Grout _ f <br /> I I Irrigation M... �.Apprpx.,,pep.th.,.-_I.l..�astem ___.__§urface Seal Installed by _ <br /> Repair Work Done 0 Type 6f-,Furnp�turbine,�£H.P. 10 -_ State Work pone�repai.ied Pump <br /> Well Destruction _Ci­W'e"li­biamefei Sealing-Material''top 50'I"` -t -- - - --- :. iA <br /> Depth Filler Material Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION f-I DESTRUCTION I I INo septic system permitted if public sewer is <br /> ' � � � r__ available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms r f ' <br /> Character of soll to a depth of 3 Leet: =F Wates`table depth i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal <br /> Distance to nearest: Well ___-Fo'i r dation Property Line <br /> a <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to.nearesc Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and_x- <br /> .rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person ins nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followi I ertify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cali r <br /> The applicant or r quired ' spections. Complete drawingon reverse r <br /> SiSigned X <br /> 9 Title: Date: 11 1 09 <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date-2—A741 Area <br /> Pit or Grout Inspection by Date Final Inspection by r Data `n <br /> Additional Comments: <br /> ❑ Stk 486-6781 LI Lodi 369-3621' ❑ Manteca 823-7104 LI Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 3 <br /> FEECK <br /> INFO AMOUNT DUE 4 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 124(REV.i/H sl <br /> EH 14-4-2a <br />