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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PAYMENT t Telephone (209) 466-6781 RECEIVE® PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FEB 2 1 f990 r (Complete in Triplicate) SAN JOA UIQ TY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the t.4%J?COUQ made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the /� p' ��dQ�d�tron is Local Health District. rru�e� AiOW A.t" .fob Address 2288$ So. Kasi on Road City Banta Lot Size unknown PM Owners Name Doff Property t Adjacento Banta FuelTerminal Gary Imhoff Address --- 4— � on NE s, e o property Phone 209-836 Contractor '�..- /1 i�G>r//N Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP 1NSTALLATiON ❑ 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 i 7 Industrial ❑ Open Bottom CJ Manteca Dia. of Well Excavation Dia. of Weil Casing 11 Domestic/Private L-1 Gravel Pack � Trac yy� I Y Type of Casing i'1 Public 1'f'C7ther f 1 Delta Specifications Depth of Grout Seal IrriType of Grout I I gation -. Approx. Depth f I Eastern -- Surface Seal Installed by Repair Work Done U Type of Pump H.P. -- Well Destruction ❑ Weil Diameter State Work Done _ Sealing Material (top 50'1 Bdntonite Pellets or Cement Slurry Depth I Filler Material igelow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1 ! DESTRUCTION I i (No septic system permitted if public sewer is Installation will serve: Residence i Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feel eet: SEPTIC TANKC7 Type/Mfg' Water table depth PKG. TREATMENT PLT. ❑ 1 Capacity No. Compartments Distance to nearest: Well Method of Disposal I Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER HEDDistance'!; _ L�\ CI nearest: Well Foundation j Property Line j SEEPAGE PITS I I Depth I Size i SUMPSr — Number ) L I Distance to nearest: Well Foundation } DISPOSAL PONDS [1 Property Line I hereby certify that ( have prepared this application and that the work will be done in accordance with San Jbaquin county ordinances, state laws, an rutes 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 no 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: "l certify that in the Performance of the work for which this ermif is issued, 1 shall am to tion laws of California." I p p y persons subject to workman's compensa The applicant mu call for ap required inspections. Complete drawing on reverse side. Signed X Title: Project na er Becker Date: 19 Feb. 1990 �1 ack FORD A M ONLY Application Accepted by ( ^� r v} �� Date Area Pit or Grout Inspection by �' Date Final Inspection by t Additional Comments: �Do ❑ 5tk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Pormit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 } FEE AMOUNT DUE INFO AMOUNT REMITTED H RECEIVED BY DATE PERMIT NO. EH 13-241REV.iin5r EH t4-2U (d/tet 0 0 I