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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 r PERMIT EXPIRES YYEAR 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 r 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 18846 N T4icrhwav D9 City I0ii Lot Size T'220 Aer�,r PM f Owner's Name Goehring Meat Address Same Phone 464 13 9 3 q Contractor .Clark- We Yl Address 2024 E. Charter License No371°560 - Phon — TYPE OF WELL/PUMP: NEW WELLXXX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.+1 010-r PROP. LINE _2-5-!- FOUNDATION AGRICULTURE WELL OTHER WELL r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr El industrial ❑'Open Bottom 71 Manteca Dia. of Well Excavation Dia. of Well Casing 12 3 4 ❑ Domestic/Private kGravel Pack ❑ Tracy Type of Casing Steel Specifications 8 gage Xkl3fublic ❑Other 17 Delta Depth of Grout Seal 240 r Type of Grout 9 Sack I I irrigation Approx. Depth I ) Eastern Surface Seal Installed by others _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ ,1 We 11 Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50 -- k TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is a} - available within 200 feet.) r Installation will serve: Residence_ Commercial_ Other i !Number of living units: I• 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. ❑ .{ f Method of Disposal :1 Distance to nearest: Well t�Foun'dation Property Line LEACHING LINE ❑ 'j No. & Length of lines �A Total length/size FILTER BED ❑:s Distance to nearest: Well Foundation Property Line SEEPAGE PITS I III Depth Size Number SUMPS ❑II 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 ^ f rules and regulations of the San Joaquin Local Health District. Z� 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 emplDy any person in such manner as to become subject to workman's compensation laws of California." Contractor's Hiring or sub-contracting signature t certifies the following: " the rforma a of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif I The applicant u c f al re rred s ction Complete drawing on reverse side. t Signed X Title: VP Clark Well Data: 17 Oct 19 8 8 F. FOR E USE ONLY r Application Accepted by Date f��f � � Area Pit or Grout Inspection by Claw.I�L Final Inspection by Date Additional Comments: ❑f Stk 466-6781 Lodi 369 362 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE "PERMIT'NO,INFO CASH ♦�EH 13-24(REV.1/H5) • U�a r0-17 EH 14-26 f ttt��V// / l