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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES I'YEAR FROM DATE ISSUED F I" R 21 4990 ( Application is hereby made to the San I (Complete in Triplicate) SAN JOAQUIN COUNTY Joaquin Local Health District for a permit to construct and/or install PUBLIC HEALTH SE�2111��5 made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules an Regulations �i Sa Paquin Local Health District. Job Address 22888 So. Kasson Road Banta City Lot Size unknown Alongside Banta Fuel Owner's Name Westside E ixipment Co. Address Terminal on East side 209-•835-0698 � , of Property Phone Contractor . /�� Address License No. Phone_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SVCA Vadose Wells - SEWER LINES DISPOSAL FLD. IN LE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS PROP,ROP. L f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E i_] Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation C-1 Domestic/Private Dia. of Well Casing L� Gravel Peck X1 Tracy Type of Casing I'! Public X] Other 11 Delta Depth of Grout Seal Specifications I i irrigation ApproI . Depth I I Eastern Type of Grout t r Surface Seal Installed by I Repair Work Done (A Type of Pump H P p State Work Done Well Destruction ❑ �1 Well Diameter Sealing Material (top 50'1 Bentonite pellets or cement Slurry Depth ( Filler Material 18elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDI I I I DESTRUCTION I 1 (No septic system permitted if public sewer is ' Installation will serve: Residence� Commercial� Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:r SEPTIC TANKTypelMfg t Water table depth ❑ Capacity PKG. TREATMENT PLT. Ll " No- Compartments Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No, &Length of lines FILTER BEDTotal length/size ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth I Size Number SUMPS 1.1 Distance to nearest: Well . Foundation DISPOSAL PONOS [] t Property Line 1 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, an rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature X, 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, f shalt employ persons subject to workman's compensa- tion laws of California." 11 i i The applicant mu ca11 for all re uired inspections. Complete drawing on reverse side. Signed X Titre: Project Manager 19 Feb. 1990 Jack Becker Date: R D MENT USE ONLY Application Accepted by Date (/ Area Pit or Grout Inspection by �— Dai Fina Inspect( by Date �~ Additional Comments: ❑ SO 466-6781 ❑ Lodi 369-3621 0 Manteca 823-71 04 5-63 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazelton B3 Ave., P O. Boz 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED By EDATE PI=RMt7't�0. • ER 13.24(REV.i i n sl , EH 14-2e y� / CT,