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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT Telephone 12091-466-6781 IA(ot 3ut2FVEC>£rj/IE13 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) JUL 2 7 1989 Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of instj � �escribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 18&2 for well/pump and theleml AfatpgMT7 a San Joaquin Local Health District. /SERV10ES LSH t( Job Address 16777 Howland Road City Lathrop Lot Size PM \ Owner's Name J• R. Simplot; Company Address P.O. Box 198, Lathrop CA 95330 phone 209 858-2511 Contractor Howk Systems Address 1825 Yosemite, Modesto License No.479018 Phone209/529-4110 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 T PITS ISUMPS 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 I'] Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ I I Irrigation —.-Approx. Depth I 1 Eastern Surface Seal installed by Repair Work Done >(I Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material /top 50'') 4 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION [ 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 r 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 l I Depth Size Number SUMPS Cl 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,1 shall employ persons subject to workman's compensa- tion laws of California." Theapplica t c for re re ec' Complete drawing on reverse side. * FACILITY MAPS ATTACHED Signed Title: Environmental Technician Date: 07/25/89 i R [DEPARTMENT USE ONLY `� �f t G Application Accepted by r" Date I � ' Area Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: C] 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 RECEIVED BY DATE PERMIT NO. INFO CASH + EH 13-241REV.tia51 EH 14-M �' J