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APPLICATION FO~ PrR is <br /> - Sr:N �: .�� L�1,n_ _.—I.i I RIC <br /> ' ! 1601 E, hA2ELTON AVL_ ST '.tTGft, CA <br /> PERM <br /> v NO.T I <br /> Telephone (Z09) 466-5781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LATE ISSUED <br /> (Complete in Triplicate} <br /> Application is hereby made to the San Joaquin Local Health District for a pew it to construct and/or install the work herein <br /> described. This application is made in compliance with San Joaquin County Ordinance No. 544 for sewage or No. 1862 for well/pump <br /> and the Rules and Regulations of the San doaauin Local Health District. <br /> Job Address 15299 N. Alpine Rd. <br /> Owner's Name Carl jv�e-ttler Subdivision Name <br /> Address 15299 N. Alpine Rd. phone <br /> Contractor's Name G©ERRING PUMP License No. 309031 <br /> Phone 727-5548 <br /> TYPE OF WELL/PUMP 14ORK: NEW WELL DWELL REPLACEMENT ' <br /> ENT L] DESTRUCTION U <br /> PUMP INSTALLATION E SYSTEM REPAIR MC OTHER �I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLp. PROP, LINE <br /> FOUNDATION _ ` AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C r <br /> I J Industrial _ DNSTRUC3ION SPECIFICATIONS <br /> �_J Open Bottom Manteca Dia, of Well Excavatior <br /> LJ Domestic/Private Gravel PackTrac <br /> I--] Public �k y Dia, of Well Casing <br /> _ IJ Other U Delta <br /> irrigation Tyke of Casing <br /> Approx. Eastern <br /> ❑ Cathodic Protection Depth Specifications <br /> Geophysical Depth of Grout Seal <br /> U Other Type of Grout <br /> Sub. H P 3 Surface Seal Installed by <br /> Repair Work Done Type of PumpU . State Work Done changed <br /> Well Destruction -"" <br /> Well Diameter Sealing Material (top 50') L1Irl — Ul <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION �l— � <br /> REPAIR/ADDITION [7) (No septic tank or seepage pit permitted if public sewer is <br /> Installation will serve: Residence _ Commercial Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Lot size <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKU Type/Mfg Water table depth <br /> t <br /> artme <br /> Compns <br /> PKG. TREATMENT PLT. � Type/Mfg Capacity No. — <br /> SEWAGE SYSTEM Capacity Method of Disposal <br /> DESTRUCTION Distance to nearest: Well Foundation <br /> Property Line <br /> LEACHING LINE U No. & Length of lines <br /> Total length/size <br /> FILTER BED Distance to nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS Depth Size k <br /> Number <br /> SUMPS <br /> I_I Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I s not employ any person in such manner as to become subject to workmant compensation laws of California." <br /> Contractor's Kiri rIub-contracting signature certifies the following: "I certify that in the performance of the work for which <br /> this permit is S I shall employ persons subject to workman's corpensatian laws of California." <br /> The applicant i�f all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Title: Bk Y. Date: 0 3 1 0 <br /> FOR DEPAR ENT U NLY <br /> Application Accepted by C Area <br /> Additional Comments: Stk 466-6781 <br /> Pit or Grout Inspection byLodi 369-3621 <br /> Date l� anteca 823-7104 <br /> Final Inspection by /ley pate <br /> Applicant Return all co ies o: o Tracy 835-5385 <br /> P �4onmental Health ermit/Services I60 E, PZelpon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY PERMIT N0, <br /> INFO DATE <br /> EH 13-24 REV, 10/82 <br /> 14-26 10/82 500 <br />