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l ' - APPLICATION FOR PERMIT ECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA J U L 2 3 19910 Telephone (209) 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT/SERVICES (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 606 F_ Annan I n- City Lot Size PM 4 Owner's Name SCOTT PYLICAN Address __6-060 E. Hogan...l.n..,,.,.,-Lodi Phone 17754 N. Hwy. 88 Contractor Goehring PUMP AddressLockeford, Ca. _License No. 309031 Phone_727-5548 TYPE OF WELL/PUMP: if' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION XX "SYSTEM REPAIR ❑ OTHER ❑ .!I. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE i TYIPE OF WELL;_—PROBLEM AREA =CONSTRUCTION SPECIFICATIONS "�,�`�-"�� -- ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I-1 Public Ci Other ❑ Delta Depth of Grout Seal Type of Grout I i Irrigation �I.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done )U Typef of Pump l' H.P. HP Suh- State Work Done replaced_old pump Q) Well Destruction ❑ Welh�Diameter Sealing Material (top 50'1 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 I M , available within 200 feet.) Installation will serve: Residepnce_ Commercial_ Other , Number of living units: �1 Number of'bedrooms� T Character of soil to a depth f3 feet: Water table depth SEPTIC TANK El Tkype/Mfg "- Capacity No_ Compartments PKG. TREATMENT PLT. ❑ IIS ,;; Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE ❑ Nf. & Length of-fines Total length/size FILTER BED ❑ Distance to nearest: WL-11 Foundation Property Line . ,l SEEPAGE PITS l 1 Depth Size r� Number SUMPSL� Distance to nearest: well` Foundation p- Property line DISPOSAL PONDS ❑ ill '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, ander' rules and regulations of the Sari Joaquin Local Health District. Home owner or licensedage 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 a ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: " k n the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californ' The applicant mu t d inspections. Complete drawing on reverse side. Signed X Title: Date: 07/20/90 i FOR DEPARTMENT USE ONLY Application Accepted by �I Data Area Pit or Grout Inspection by !.! Date Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ Lodi.[369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to.Environmental Health Permit/Services 1801 E. Hazellon Ave., P.O. Box 2009, Stk., CA 95201 ]NF0 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. +.EH 13-24/HEV.1/H sr ` EH 16-29 f� 7 —2—/—1TJ -f CK III ,