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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address City Lot Size PM Owner's Name Address --U-845 N. Hwy, 99 Phone 17754 N. Hwy./88 Contractor Goebring Pump _Address Lockeford Cd. License No. 309031 Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION IN SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE -TYPE OFWEL-L" -PROBLEM AREA - 'CONSTRUCTiON SPECIFICATIONS' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing . ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l"1 Public Ll Other rl Delta Depth of Grout Seal Type of Grout I I Irrigation _.,Approx. Depth I I Eastern Surface Sedl Installed by Repair Work Done ❑ Type of Pump H.P. 2 - 1' 5u�� — 1 _ State Work Done ub Weil Destruction ❑ Well Diameter Sealing Material (top 50') Depth. Filler Material (Below 50') �+ TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Installation will serve: Residence_ Commercial— Other available within 200 feet.) Number of living units: - Number of bedrooms Character of soil to a depth of 3 feet. t ' ` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Properti Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number . SUMPS ❑ 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 laws, and rules and regulations of the San Joaquin Local Health Diltrict. Home owner or licensed age '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 suc nner s to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature a certifies the following: ' ify 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 Califor The applicant m[ r I required i spections. Complete drawing on reverse side. Signed X Title: Rkpr Date: n9l I itsg FOR DEPARTMENT USE ONLY Application Accepted by Date 47-1 � Area � r Pit or Grout Inspection by Date Final lnspectio- L-0-1- Date I Additional Comments: r ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 95201 X4\ FEE CK X INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT'N0. +.EH 13-24 IREV.1/851 S 1 Iw _J{ ` PEER 11 EH 14-28 L_/ �l 7 11¢-YJ I/ CP