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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA V �V Telephone (209) 466-6781 6 08 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED SSP 2 (Complete in Triplicate) NVIRONMENTAL fJEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work er ffRMkTi6Si*rP lication is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin ` Local Health District. Job Address 17390 Kr6ll Rd. City Lodi Lot Size PM Owner's Name GENE WHEELER Address 17390 Kroll Rd. , Lodi Phone Lockeford Contractor Goehrinq Pump Address 17754 N. Hwy. _$.`License No. 309031 Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ID DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIRXX OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom^ ❑ Manteca 136.of Well Excavation Dia. of Well Casing ❑ Domestic/Private 0 Gravel Pack~ ❑ Tracy Type of Casing Specifications * Public ❑ Other _ f_7 Delta-' Depth of Grout Seal Type of Grout I I A Irrigation /prox--Depth I i Eastern Surface Seal Installed by g- -� p Repair Work Done *1 Type of Pump Sub. H.P. 2- - State Work Done replaced t:.Lirb n(l W/ Well Destruction ElWell Diameter . Sealing Material (top 50') submersible Filler Material (Below 50') - TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION l 1 DESTRUCTION t I (No septic system permitted it public sewer is f 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 _L _—` _._._ - Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal s Distance to nearer): Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines __ "<'`''1, Total length/size FILTER BED ❑ Distance to nearest: Well Foundation - _ Property Line SEEPAGE PITS i I Depth Size Number T SUMPS Ll 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. Homer owner or licensed age Ys 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 suc anner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followin ify 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 Califo i . The applicant m r II quired inspections. Complete drawing on reverse side. s Signed X Title: _— --- - Bkpr. Data: 09/23/88 FOR DEPARTMENT USE ONLY Application Accepted by r j Date Area Pit or Grout Inspection by Date Final Inspection by Date f Additional Comments: ❑ Stk 456-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 FEE INFO jAMOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED BY DATE PERMIT-NO. + EH 13-24 iRf_V.1/N 51 EH 14-28 �2-=7