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J: ' APPLICATION FOR PERMIT s SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVE® PERMIT EXPIRES 1-YEAR FROM DATE ISSUED FEB 21 1990 (Complete in Triplicate) pSAN JOAQUIIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install th@.� er��r� I t� lication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and 1W&KAr9 k WdWWoaquin Local Health District. Job Address 22888 South Kasson Road city Banta Lot Size 675 X 675 PM Owner's NameChOvran U.S.A. , Inc. Address 2410 Camino Ramon San Rawn,CA Pnone4.15 8 - 9525I Contractor /��7/ I Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ �I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER It SVCA VadoSe We 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack XXTracy Type of Casing Specifications Fl Public xxOther C] Delta Depth of Grout Seal Type of Grout I I Irrigation _.-Approx. Depth l 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump I H.P. ip State Work Done Well Destruction ❑ Well Diameter 1 Sealing Material (top 50') Bentonite net 7 PfiG or ,cement S111rry i Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION f.l REPAIR/ADDITION i I DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other I Number of living units: Number Iof bedrooms , Character of soil to a depth of 3 feet: J Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments IE PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length'of lines g Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth I Size Number SUMPS ❑ 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, I shall employ persons subject to workman's compensa- tion laws of California." 1 The appli7tJ call fo all r quired inspections. Complete drawing on reverse side. Signed X Title: Pr j ect Manager Date: 19 Feb. 1990 Becker ENT USE ONLY ' Application Accepted by (� Date D� Area Pit or Grout inspection by Date Fina! Inspection by ~` Date Additional Comments: ' ' ne _ a LJ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 -- 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 INFO CASH RECEIVED BY DATE PERMIT NO. ..EH 13-24(REV,i i H 5; „ , O fl �. EH 14-2e �.. `-I