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F APPLICATION FOR PERITT SAN JOAQ6 N LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) VIN in OCT 4 — 1084 PERMIT NO. :SAN JOAQUiN LOCAL' ISSUED HEALTH DISTRICT. 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 wel3/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address .3.7-$-E* N. HWY. 88 Subdivision Name Owner's Name KEMALYAN & LARSON AddreE .0 , BOX 7041, Stockton, Ca. Phone Contractor's Name Goehrina Pump License No. 309031 Phone 727-5548 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT DESTRUCTION PUMP INSTALLATION SYSTEM REPAIR OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 'J Industrial U Domestic/Private �] Public LjIrrigation ❑ Cathodic Protection_ L7 Geophysical U Other Repair Work Done N Well Destruction TYPE OF WELL PROBLEM AREA U Open Bottom F-1 Manteca Gravel 'Pack ' -F1 Tracy' Dl CONSTRUCTION SPECIFICATIONS Dia. of Well Excavation Dia, of Well Casing- - LJ Other L_J e to Type of Casing Approx. Q Eastern Specifications Depth Depth of -Grout Seal Type of Grout _ Surface Seal Installed by sub. H.P. 3 state Work Donereplaced old turbine Sealing Material (top 50') _ Filler Material (Below 50') Type of Pump Well Diameter Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDIT,ION �. (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) Installation will serve: Residence _ Commercial _ Otlier Number of living units: Number of bedrooms Lot size Character of soil to a depth of 3 feet: _ ' _�^^ Water table depth SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity1. Method of Disposal SEWAGE SYSTEM Distance to nearest: Well t Foundation } Property Line DESTRUCTION LEACHING LINE U No. & Length of lines Total—length/size FILTER BED Distance to nearest:' Well Foundation Property Line SEEPAGE PITS D ', Depth Size Number SUMPS., - U Distance to nearest: Well Foundation Property Line DISPOSAL. PONDS 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 regul-ations of the San Joaquin Local Health District. 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 sh 1 of employ any person in such manner as to become subject to workman compensation laws of California." Contractor's hir' -contracting signature certifies the following: "I certify that in the performance of the work for which this permit is ' shal employ persons subject to workman's compensation laws of California." The applicant m fo 11 required inspections. Complete drawing on reverse side. Signed XTitle: Bk r . Date: F 4011)TMINT,1.110 Y Application Accepted by Area Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection -,by Date Manteca 823-7104 Final ,Inspection by Date / tj Tracy 835-63$5 Applicant - Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Avd7; P.O. Box 2009, Stk., CA 95201 FEE BASE I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT ND. INFO — 4�9r��{ �5�-1-�3Cab L� EH 13-24 REV. 10/82 10/82 500 14-26 S