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APPLICATION FOR PLRNi1T z I SAN JOAQUiN LOCAL IFA1_T4 DISTRICT - E p1661 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466-6781 DATE ISSUED PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) - ` Application is hereby made to the;San Joaquin Local Health District for a permit to construct anC/or install the work herein described. This application 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 5324 E. Live Oak Rd. Subdivision Name Owner's Name Eugene Lind Address Same as above Phone Contractor's Name GoehringiPump License No. 309031 Phone 727-5548 TYPE OF WELL/PUMP WORK: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f + INTENDED USE TYPE OF WELL PROBLEM AREA ; CONSTRUCIION'SPECIFICATIONS . ' -1—Dia. I•ndustri�al--� - -U Open,Bottom �- ❑•Manteca -of Well:'Exeavation '" "M U.Domes.tic•/Pr,i•va.te_-¢ _ 06ravel-Pack,*-:R!�rac-y=-�-��.. F"ia�of'We11y6asing�. -=---_-- —� Public Other Delta ; ❑ ❑ # ❑ Type of Casing Lj Irrigation Approx. ❑ Eastern Specifications Cathodic Protection ❑ Depth M Depth of Grout Seal - (\ Geophysical1 Y� L] T� Type of Grout t ❑Other Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter 8" Sealing Material (top 50') Concrete . .- Depth 120' Filler Material (Below 50') washed TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ (No septic"tank or seepage pit permitted if public sewer is i available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Lot size " s Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION LEACHING LINE No. &`Length of lines Total length/size ' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS Cj Depth7 Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line . _,,i,� ,.,,.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 f permit is issued, I all not employ any person in such manner as to become subject to workmanis compensation laws of California." Contractor's hi r sub-contracting signature certifies the following: "I certify that in the performance of the work for which j this permit d, I shall employ persons subject to workman's compensation laws of California." �. The applica for all required inspections. Complete drawing on reverse side. Signed X Title: Bk Y . Date: 10/30/.S 6 FOR DEPARTMENT USE ONLY Stk 466-6781 Application Accepted "� _Area Lodi 369-3621 Additional Comments: ti 3 Pit or Grout Inspection. Date L] anteca 823-7104 Final Inspection by t Date L7Tracy. 835-6385 k Applicant - Return all copies F : ironmental Health Permit/Services 16 E. H zeltan Ave., P.O. BQx 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE �W PERMIT NO. INFO 11/2 . a jl 10/82 500 EH 13-24 REV. lO/82 j - 1--7 1 61 14-26 1 4