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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (208) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 5 3988 (Complete in Triplicate) ! Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install thevt� TNis'dliE`ation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the RulesPMUG VI" an Joaquin Local Health District. t Job Address 18846 N 4 Hwy. .'99, City Lodi Lot Size PM Owner's Name GOEHRING MEAT Address P.4.Box 147, Lodi , Ca . Phone Contractor Goehring Pump -Address P•0 -Box 113, _LOCkefardse No. 309031 Phone 727-5948 TYPE OF WELL/PUMP: 1 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION ❑ SYSTEM REPAIR Z OTHER ❑ a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _', �� INTENDED USE TYPE OF WELL 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 `r FI Public 71 Other ❑ Delta Depth of Grout Seal Type of Grout I t Irrigation —.-Approx. Depth I I Eastern Surface.Seal Installed by _ Repair Work Done (X Type of Pump turbi e H.P. 20 State Work Done_repaired howl Well Destruction ❑ Well Diameter Sealing Material (top 501) Depth`? Filler Material iBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i I! DESTRUCTION I 1 lNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: s Number of bedrooms Character of soil to a depth-of,3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ — Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines, t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth {" Size Number SUMPS ❑ Distance to nearest: Well Fourrdatioh Property Line . R 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';Irict. 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)^annpr as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foHowin ' eirtify 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 Calif, _ The applicant ora required inspections. Complete drawing on reverse.side. Signed X Title: _-'Bkpr Date: 08/11/88 1 FOR DEPARTMENT USE ONLY Application Accepted by Date _ZZ A Area" Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk'i 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.D. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASHCK RECEIVED BY DATE Q�PERMIT'/Nf o. i r.EH 13-2418 EV.t/Ksl EH 14-2e 35 Ij 4JY t{J4/'