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L. APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone 1209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (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. 1M2 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address city Manteca Lot Size PM 1111 139th St. , SAn Leandro, CA Owner's NameGolden Grain Company AddressXNXkXRXkXXMNXXNVXXX Phone 415 357-8400 1401 Halyard, STe. 140 Contractor Groundwater TEchnc kmgy WEst Sacramento License No. Phork91 6 372-4700 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERS soil-gas survey DISTANCE TO NEAREST: SEPTIC TANK ""'— SEWER LINES 50 f t. DISPOSAL FLD. --- PROP. LINE 5 f t FOUNDATION 30 ft. AGRICULTURE WELL --- OTHER WELL 1 00 fpyTS/SUMPS —— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom E1 Manteca Dia. of Well Excavation fl 7 F,7 r, Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing none Specifications f"1 Public p Other F Delta Depth of Grout Seal 10 r Type of Grout benton i t e i I Irrigation 1-0-.'Approx. Depth I I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material stop 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) f h Installation will serve: Residence_ Commercial Other V)l r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water tabledepth SEPTIC TANK ❑ Type/Mfg Capacity NoRl00 _tdlif �rmewrls +I PKG. TREATMENT PLT. ❑ IV Disposal u �t Distance to nearest: Well Foundation Property Line Fr6J J LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lirie��.'.v `lv„1L,1 Cr��1f1 SEEPAGE PITS I I Depth Size Number SUMPS 0 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 taws, 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." The applicant must call for all required ins ctions. Complete drawing on reverse side. Signed x Title: Geologist Date: 8/2I89 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date ��Fiinall Inspection byDate Date Additional Comments: W,7? �/ W ild 4Gr� 4V,�&i IY[.[.�[..�K to (1./ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 9 ❑ Tracy 835- 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 RECEIVED BY DATE PERMIT NO. INFO + fH114-3-241Ftev.1/851 , �/Q =—Iq EH 29 -i