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APPLICATION FOR PERMIT SAN JOAQUIN-LOCAL HEALTH DISTRICT E 1601 E. HAZE T ON AVE., STOCKTON, CA l Telephone (209) 466-6781 ,PERMIT EXPIRES TYEAR FROM DATE ISSUED `t (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/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 City Lot Size PM Owner's Name EI C1RFNCE E GILES Address 23098 N. Lower Sacto. Rd. Phone } 17754 N. Hwy. 88 Contractor Goehring Pump 1 _Address LoCkeford. Ca. 95237 License No. 309031 Phone_7275548 TYPE OF WELL/PUMP: ' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONNA PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'] Public 1-1Other .I Ll Delta Depth of Grout Seal ' Type of Grout I I Irrigation _..Approx. Depth i I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction [A Well Diameter 811 Sealing Material (top 50') 6— k sfurry mix Depth 481Filler,Mate6alil8 low 50'1 -- r � TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION [ I -DESTRUCTION I I (No septic system permitted if public sewer is by }t . . °"• available within 200 feet.) C f Installation will serve: Residence_ /Commercial____ Other Number of living units: Numbertttt of bedrooms Character of soil to a depth of 3 feet: 'I Water table depth SEPTIC TANK ❑ Type/Mfg I Capacity ° No. Compartments PKG, TREATMENT PLT. ❑ , - Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER HED ❑ Distance to nearest: Well Foundation Property Line _r SEEPAGE PITS 11 Depth I Size Number SUMPS L] Distance to'nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 s manner as to become subject to workman's compensation laws of California7' Contractor's hiring or sub-contracting signature certifies the followi certify that in the performance of the work for which this permit is issued, l shA'employ persons subject to workman's compensa- tion laws of Calif The applicant I for II required inspections. Complete drawing on reverse side. Signed Title: Bk r. Date:10/02/90 FOR DEPARTMENT USE ONLY Application Accepted by Date _ C) Area 2 Pit or Grout Inspection by Date Final Inspection byl� Rate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 L1 Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. INFO r�- v rr, aEH 13-24(REV.IIR5) V EH 14-28 ��