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_ G-U J✓ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1C`01 E. HAYELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health D-noct for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.539 fur sewing or No. t8rk for weN'pump and the Rules and Regulations of the San.Ioaquin Lacal Health District. Job Address __1_&&4.6 R Q.6 I1L_N_? 11W.1y__99- ---- City i.O&i Lot Size *3oAezG g Pm — owner's Name GOehring-Meat____-_-____ Addrr, __. same _ ___- --.-_ Phone 464 1 393 _ Contractor Clark Well Address_202.4_�E_Chart�eX _License No3Z5fi0_—F, .e4.fi2r TYPE OF WE,L/PUMP; NEW WELLXXX WELL REPLACEMENT DESTHUCTION Ci PUMP INSTALLATION ( SYSTEM REPAIR (1 OTt;ER L-1 DISTANCE TO NEAREST: SEPTIC TANK _— SEWEP. LINES _---_— DISPOSAL FLD*_M0_'PROP. LINE 7S'r FOUNDATION —_._—.__.. AGRICULTURE WELL — _. OTHER WELL 1 PITS/SUMPS _ INTE'JDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -- Dia.of Well Cas;ng 12_2L4" Ll Industrial LJ Open Bottom l; Manteca Dta. of Well Excavation C) Domestic/Private }f.kGravel Pack 1 Tracy Type of Casing_.Stee 1— Specifications 8 gage r Xkyublic f 1 Other I Delo Depth of Grout Seal ._240—__-- Type of Grout-9___$£l,t;�k _.. a I I Irrigation .. Apjxox. Depth i ! Eastern ;iurtar'e Said Installed by —_—Qs�1e3. _--- — Repair Work Done U Type of Pump ____ --_ it P. ___ _--- ----__--- State Work Don,- Well Destructinn ❑ Well Diameter __._ ____. Seii-ng M•iterial Itop 50 1 -_— --- - -- M Depth _____ Filler Matenal(Below n,") TYPE Of SEPTIC WONK: NEW INSTAI LATION J?[Pz fl/ADDITION : DLSTHIJCTION I 1 (No septic system permitted it public sewer rs �1 available within 200 feet.) � Installation will serve: Re-,0ence_.__ Commeru.J— Other--.-- - _-_ __ Number of living units: Number of bedrot-ms Character of soil to a depin of 3 feet: . __ --__—_.-----___-- --- ----. _.—Water table depth -- SEPTIC TANK I 1 Type/Mfg __.___--_—____ —__-- Canauty ._.__._—.—_ No. Cump3riments PKG. TREATMENT PLT.1 1 Method of Dispowl -- — Distance to nearest: Well __ Foundation_ _. __.- __. Property Line LEACHING LINE 1 : No. S Length of hn,•s Total length/size______ FILTER BED O Distance to nearest W1•II _.._ Fo.indetion _-- _ Property Line_—_--_- SEEPAGE PITS I Deptt` - --- ----.S,e .. __-- - -- -__.-._-- - - Number----------_-- SUMPS I Distance to oearese Well . Foundation _-_______— Property Line DISPOSAL PONDS 1 hereby certify that I have prepared this application and that'ie wnrk will tie dune III accordance with San Joaquin county ordinances,state laws,and ^ rules and regulations of the San Joaquin Loral Heath D=Inst Home owner or licensed agent's signature sonifies the fouow,•Ijj 'I c"ify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to beconve subject to w'urkn—'s compensation laws of California"Co.Nraetor's hiring or sub-contfacift signature certifiestho following:,'._q4rMr3 Ike rfoirrartca of the work for which this permit is issued.I shall emrloy persr,ns subject to workman's eompensa tion laws of Calif a... The applicant c f aIJ •tied s bon: Compiwu drawing on reverse side Title•VP Clark Well Date: 17 Oct 1988 Signed X_ _� -� i" - - - - ----- ------------- - j FOR OEPARTMENT USE ONLY Application O.ccePtad by —�= -_.- ,- -.--\) �`= ��`" -a--- Date . —t— Area— t e / ci.�►/"�.�� Pit or Grout Inspection by _ _ ��'S!t�t¢- Dz-,/07� 1.� ci'ial I-isperhnn by ... .-_. — Data _ Additional Commems��!__`i��t------...11z . � _ "yd.•s: _V�--}-►i.,L_ �_`:�_ C Stk 4666781 LiX1i 3693521 Mantwca 823 i104 i i Tracy 835 6385 Applicant- Retum all copies to Envoonmontal Health PnrinttrServicec 160'. E. Hazelton Ave., P.O. Box 2009. Stk., CA 95201 FEF AMOWT'DUE —1—�•'%'r�'�T Ill:!iT1E0 �4Srr h'CEtvEO 9y DATE PERMIT NO INTO --.—._..-i— .__. ------�---- -------- - ` . EN 1371:Rfv1 i ��