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Ready for inspection APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT NO. Telephone (209) 466--6781 DATE ISSUED PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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. Job Address 1028 Indiana, Woodbridge Subdivision Name Owner's Name Haryey. M nde7 Address 110 Miller AVe+ an Jose�ho&5127 Contractor's Name Goehring PUMP _ License No. 309031 Phone 727-5548 rn TYPE OF WELL/PUMP WORK: NEW WELL L] WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER U 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 U Open Bottom Manteca Dia, of Well Excavation Domestic/Private- Gr&veF Pack Tracy Dia. of Well Casing --� Public F—I Other Delta Type of Casing V Irrigation Approx. Eastern Depth Specifications Cathodic Protection Depth of Grout Seal 1__� Geophysical • Type of Grout U Other Surface Seal Installed by Repair Work Done [X Type of Pump ;Sub. H.P. 1 State Work Done gepiac6d Well Destruction F-1- .Wel 1,.Di_ameter Sealing Material (top 50') _ Depth Filler;Material (Below 50'} TYPE OF SEPTIC WORK: NEW INSTALLATION U REPAIR/.ADDITION J (No. septic tank or seepage pit permitted: if public sewer is w ------ave-l-able within 200 feet.) Installation will serve: Residence _ Commercial Other -^— Number of living units: Number of bedrooms Lot size"'' Character of soil to a depth of .3 feet: WateM table depth SEPTIC TANK Type/Mfg. Capacity No. Compaftments PKG. TREATMENT PLT, Type/Mfg Capacity Method of Disposal SFWAGE SYSTEM Distance to nearest: Well Foundation Property Line DESTRUCTION � LEACHING LINE ❑ No„& Length of lines `" Total length/size FILTER BED Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line, DISPOSAL PONDS CI 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 ag is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 not employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hiri s -contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is s Sha)I employ persons subject to workman's compensation laws of California." The applicant u f 11 required inspections. Complete drawing on reverse side. Signed X Title: Bkpr. Date: 06/25/85 PARTMENT US NLY 6" Application Accepted by Area Stk 466-6781 Additional Comments: A Lodi 369-3621 Pit or Grout Inspection by Date LL Manteca 823-7104 Final Inspection by Date b/ Z/--- r 0 Tracy 835-6385 Applicant - Return all copies to; it nmental Health Permit/Services 1601 F. Hazelton ve., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO _S EH 13-24 REV. 10/82 10/82 500 14-26