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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 6d Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 5 1988 (Complete in Triplicate) Applicat-nn is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the viWRht'r1'tfftll4s>;Y A Tf1� IL'ation is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the RulespkwR�l"Vl" an Joaquin Local Health District. Job Address 18846 N.., Hwy. 99, City_T Lodi Lot Size PM Owner's Name GOEHRING MEAT Address P•0.Box 147 , Lodi, Ca . Phone ! Conlractor GOehring Pump _Address P•0 •Box 113,,- LockefQXdlse No. 309031 -Phone_ 727-554 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications 1'1 Public 71 Other 11 Delta -` -Depth of Grout Seal _ Type of Grout I ; Irrigation Approx. Depth I I Eastern Surface-Seal Installed by Repair Work Done [X Type of Pump turbi e H.P. 20 State Work Done repaired bowl Well Destruction ❑ Well Diameter Sealing Material (top 50'1 DepthL Filler Material !Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION : 1! DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence== Commercial_ Other i Number of living units: i Number of bedrooms y' Character of soil to a depth-of.3 fe8t: Water table depth SEPTIC TANK ❑ Ty'pe/Mfg F Capacity___ No. Compartments _ PKG. TREATMENT PLT. ❑ -- -i Method of Disposal Distance to nearest: Well . Foundation Property line LEACHING LINE LI No. & Length of lines^ 1 Total length/size FILTER BED ❑ Distance to nearest: `. Well Foundation . Property Line _ I 1 SEEPAGE PITS l I Depth Size Number_ SUMPS (7 Distance to nearest: Well Foundation Property Line T DISPOSAL PONDS ❑ a 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 Di§trict. { 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 employ any person in such nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foNowin "I eitify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of Calif. The applicant or a irequired inspections. Complete drawing on reverse side. Signed X�._ Title: BkPr• Date: 08/11/88 FOR DEPARTMENT USE ONLY Application Accepted by . 1�/J�i1C� Date Area- .. -- � Pit or Grout Inspection by Date Final Inspection by /l Date Additional Comments: .._ ❑ Stk� 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82.3-7104 17 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEEi INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. +-EH 13-24 JR i/Kb) EH 1428 3s . ' -