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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 J. (Complete in Triplicate) made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This applicatio Application is hereby Q. made Application with San Joaquin County Ordinance No. 549 for sewage or No. 1862Lfor welll.pump and the Rules and Regulations of the San Joa 492 in Local Health District. -:t 189,50 Nl. Hwy 99. Cit caItlpCt Lot Size 1 • 5 acT E~"M. Job Address Owner's Name _ GOehring Meats Address 18846 N Hwy 99 Phone464-1393 w 371560 .462-767 Clark Well Address 2024 East Charter License No.��-_—phone Contractor. ,: DESTRUCTIONXRX OTHER O TYPE OF WELL/PUMP: NEW WELL ❑ WELt REPLACEMENT ❑ R PUMP INSTALLATION L1SYSTEM REPAIR E34 SEWER LINES l- DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS I ry FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing F .❑ I dustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications 1 Type of Casing © Domestic lPrivate CI Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout � [- ublic Cl Other F1 Delta K Approx. Depth I 1 Eastern Surface Seal Installed by I I Irrigation State Work Done j f Repair Work Done L] Type of Pump H.P. O WeR Destruction X12 Well Diameter '1-- Sealing Material (top 50'1 k note- We- are meting Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NfW INI1 Rl=PAIRIADDITION L! DESTRUCTION i I (Noavaseptic ystem ithin 200 teetiued if public sewer is l installation will serve: Residence Commercial , Other_--�- Number of living units: Number of bedrooms _ Water table depth Character of soil to a depth of 3 feet: No. Compartments ❑ Type/MCapacity i SEPTIC TANK a, f g Method of Disposal PKG. TREATMENT PLT. ❑` Line _ Distance to nearest: Well Foundation Property r Total length/size LEACHING LINE ❑': No. & Length of lines property Line FILTER BED (D: Distance to nearest: Well Foundation Number SEEPAGE PITS l i Depth °�"' �°` Size Cl Distance to nearest Well ° Foundation Property Line SUMPS - - _ D SPOSAL 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 theiSan 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 l employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 Ca-forni The applic ust or II re i ed spocti' S. Complete drawing on-reverse side. 8 Dec 1988 Title:VP Clark We'l1 Date: k Signed X ; FOR DEPARTMENT USE ONLY Date Area pplication Accepted by Z it or Grout Inspection by. Date Final Inspection by Date Additional Comments: Q Stk 466-6781 ❑-Lodi 369.3621 ❑ Manteca _823-7104 C1 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK RECEIVED(3Y DATE PERMIT NO. y� FEE 'MOUNT DUE AMOUNT REMITTED CASH INFO +.EH 13-24(REV.I/K5) EK 11-2e .