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,y APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ,y} 1601 E. HAZEL i ON AVE., STOCKTON, CA �p�6 4 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCT (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thery�varjC herein described. This application is et1}fy1 n an Joaquin made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ pump and th 1 Local Health District. /V0 0 )I-PN — f ,vac�ERMrr✓ EvICs South of,_229. S._ Maffatl S . side ofcityManteca Lot Size PM Job Address Moffat (21fi 41 5) Owner's Name Golden Grain Co. Address 1111 139th Ave San LeandrCjbhone 667-61 7H2 1401 Halyard Dr. , Ste. 140 C57 (916 ) ConfractoiGroundwater Tech. Address West Sacram Bto License No. 434343 Phone_ 3724700 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES DISPOSAL FLO. PROP. LINE 40 FOUNDATION 80 ' AGRICULTURE WELL -- OTHER WELL -- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr n g; Industrial © Open Bottom ❑ Dia. of Well Casing Dia. of Well Excavation_7,� - g ❑ Domestic/Private A<Gravel Pack E] Tracy Type of Casing PVC Specifications sand/ !' I'1 Public ❑ Other f I Delta Depth of Grout Seal 81 Type of Grout C E-IME nt 14 Irrigation -5-0Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material IBelow 501 — TYPE OF SEPTIC WORK: NEW INSTALLATION 1 7 REPAIR/ADDITION I 1 DESTRUCTION { I (No septic system permitted if public sewer is kavailable within 200 feet.l 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 Capacity Na. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. F1Method of Disposal 1 Distance to nearest: Well Foundation Property Line \ LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line F SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ F 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 F 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 1, 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." SAN JOAQUIN LOCAL HEALTH DISTRICT The applitAccepted tall d inspections. Complete drawing on reverse side. ENVIRONMENTAL HEALTH DIVISION Signed X Title: Geologist ��aRENAMT3/89 FOR DEPARTMENT USE ONLY / 'f' ApplicatiDate !0 �� Area Pit or Grout Inspection by Date Final Inspection by n� Date—fl-30- Cf Additional Comments: l.�vi C��-r �"•` �? �'W` 0 Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 0-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I i fEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO n G +-EH 13-24(FIEV.i!H5) 3500 :;L EH 14-28