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I s� a Uae3 3 f APPLICATION FOR PERMIT SAN JOAQUlN LOCAL HEALTH DISTRICT � 1601 E. HAZELTON AVE., STOCKTON, CA MAR 2 O K"?90 � Telephone 12091 466-6781 ENVIRONMENTAL HEALTH PERMIT EXPIRES 1-YEAR FROM DATE ISSUED PERMIT/SERVICES 1 (Complete in Triplicate) I J 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. r 'I Job Address 11200 N_ Lilly Road City Lot Size PM j Owner's Name KARL WOLF Address 11200 N. Tully RQad Phone 17754 N. Hwy. 88 p Contractor GOP_Ilring Pump ! AddressLockeford, Calif- License tufo. 309031 Phone 727-55 A TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR X$ OTHER ❑ k DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE —T.3 OF WELL OBLLE AREA'^ONSTAUCTIGN S`�ECIFICAT N� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing j ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing . Specifications F] Public FI Other ❑ Delta Depth of Grout Seal Type of Grout_ _ I Irrigation -_Approx. Depth I I Eastern Surface Seal Installed by _ i Repair Work Done ❑ Type of Pump Turbine H.P. 50 State Work Done _ repaired I Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is 6h available within 200 feet.) Installation will serve: Residence_ Commercial_ Other y Number of living units: Number of bedrooms- Character of soil to a depth of 3 feet.J " ' d e— ' s` Water table depth SEPTIC TANK ❑ Type/Mfg Capacity =-- No.Compartments PKG. TREATMENT PLT. ❑ ' ��a 'S� - "�'7 Method of Disposal k Distance to nearest: Well Foundation Property Line- �,f �_ I j4 LEACHING LINE ❑ No. & Length of lines r Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line f SEEPAGE PITS i I Depth Size Number F SUMPS Cl Distance to nearest: Well Foundation Property Line `. y 99 DISPOSAL PONDS ❑ 173 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, an rules and regulations of the San Joaquin Local Health District. Home owner or licensednt 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 sF-r-t"i anner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the follow; fy 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 CMf The applicantr I squired inspections. Complete drawing on reverse side. fSigned x Title: Rkpr- Date: 3/16/90 d FOR DEPARTMENT USE ONLY / y��j, J Application Accepted by /1 Date_ '2k �J Area Pit or Grout Inspection by Data Final Inspection by e &II Date - r' Tom... I Additional Comments: ❑ 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 2009, Stk., CA 95201 j FEE i k INFO AMOUNT DUE JAMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'ND. I I +.EH 13-24(REV.i/n 51 EH 14-26 �/ O �