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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT nn coax 1601 E. HAZE TON AVE., STOCKTON, CA D u Telephone (209) 466-6781 C 2 6 08i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SLP I " (Complete in Triplicate) NVIRc)NMENTAL}iEALTH raApplication is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work er �plri�tilicauon is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weltlpump and the Rules and Regulations of the San Joaquin Local Health District. Joh Address 17390 Kr611 Rd. City Lodi Lot Size PM Ii Owner's Name GENE WHEELER Address 17390 Kroll Rd. , Lodi Phone Lockeford Contractor Goehring PpTp Address 17754 N. Hwy. 88 License No. 309031 Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIRS OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELt PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia'. of Well Excavation Dia. of Well Casing 1❑ Domestic/Private L7 Gravel Pack Cl Tracy- Type of Casing Specifications t"] Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth t I Eastern Surface Seal Installed by - Repair Work Done :�L Type of Pump Sub. H.P. 2 State Work Dane replaced turhini�! w/ submersible Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth y Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence— Commercial— Other i ,*Number of living units: Number of bedrooms .Character of soil to a depth of'3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation - Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ll 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 District- Home owner or licensed age is 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 as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the followin "I 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 Califo i - The applicant mf r II quired inspections. Complete drawing on reverse side. Signed X 1 Title: Bkpr• _ Date: 09/23/88 FOR DEPARTMENT USE ONLY Application Accepted by r date y u Area Pit or Grout Inspection by Date Final Inspection by � Date Additional Comments: ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT.REMITTED CK RECEIVED BY DATE PERMiT'NO, INFO CASH • L� r EH 13.21(REV,t/n 5y SFs- 1 � EH I4-26