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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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. 1862 for wevpump and the Rules and Regulations of the San Joaquin Local Health Qistrict. ti e�_.'r 8 L� + 2Z l — 0 ZP�_CS S Job Address GRant Ave. & Moffat Blvd. (229 Moffat_ city Manteca Lot Size PM Owner's Name Golden Grain`' ny CompaAddress 1111 139th St., San Leandro CA Phone( 1357-8400 1 1401 HaLYARD, Ste. 140 1 Address License No. Rl �3724700 Contract TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I(ft_. DISPOSAL FLD. PROP. LINE FOUNDATION hn ft AGRICULTURE WELL OTHER WELL _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 04� Ria. of Well Casing ❑ Domestic/Private ❑ Gravel Pack L1Tracy Type of Casing -riDri Specifications � f'1 Public xxother I n Delta Depth of Grout Seal r Type of Grout�]pl ltnni f P 11 Irrigation Approx. Depth I i Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diamr eter Sealing Material (top 501 Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 RFPAIR/ADDITION l I OESTRUCTION f I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence L Commercial— Other iNumber of living units: Number of bedrooms Character of soil to a depth o1 3 feet: Water tattle depth � SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments _ PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line 5 ! LEACHING LINE Ll No. &Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number r SUMPS Ll Distance to nearest: Well Foundation Property Line c 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 Di§trict. 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 re uire inspections. Complete drawing on reverse side. Signed 1by It Title: (�eoog5t Date: 8/28/89 FOR DEPARTMENT USE ONLY Application Accep � Date � ✓ Area Pit or Grout Inspection by Date Date 9-� Final Inspection by ` +1 Additional Comments: O Stk 466-6781 Lodi 369-3621 ❑ Ma ca 1123-Y104 ❑ Tracy 835-6385 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 CASH RECEIVED BY DATE PERMIT NO. tNFO r 7�f a EH 13-24 1REV.I b) EH 1429