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.. j : APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT SCANNED 1601 E. .HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6783 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) DEC 12 ILM Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install,.the work'A.@A LibVd�Tf 14lication is made in compliance with San Joaquin County,Ordinance N .549 for sewage or No. 1862 for well/pump and the RI, �!aLocal Healt ��rh l he San Joaquin e 1 1 ! 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 Moorman's 2120 Wilcox Road Contractor Water 5 stems Address Stockton CA 95205 License No. 468816 Phone 209/931-321 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION E9 � PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS TM 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 O Tracy Type of Casing Specifications f'1 �p� .. Public ❑ Other CI Delta Depth of Grout Seal Type of Grout%& ,,, I I Irrigation _,--.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pum �✓P• 5ta o►k Done Well Destruction l9 Well Di meter �� ''S' ling M t ial (top 5D') fair 5� Deptft / 0" + �' r 7 Filler Material (Below 5t 1 P st [t! r Cq d�jar/N TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 1101AIR/ADDITION I I DESTRUCTION i I lNo 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. ❑ 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 Cl Distance to nearest: Well Foundation + Property Line DISPOSAL PONDS ❑ I hereby certify that i have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Diltrict. 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, 1 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 applican II f l it r ns mpleta drawing on reverse side. Signed Title. Environmental Technician Date: 12/11/89 1/ FOR DEPARTMENT USE ONLY Application Accepted by ,�"/J Date /,F 47Area ;21 s Pit or Grout Inspection byLL -- Date Final Inspection by Date-off Additional Comments: �c ("j1 47 ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl 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 K RECEIVED 6Y DATE PERMfT N0. INFO C H •-EN 13-24 IAEV.ri+tslFH 14-n a �'ti"31ao r I