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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZEL T ON AVE., STOCKTON, CA �... Telephone 12091 466-6781 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 16154 N. Alpine W. City Lot Size PM Owner's Name JACK VANDERIANS_ Address 16154 N. Alpine Rd. _ _ Phone Contractor_FIRING PUMP Address 17754N. M. 88 L0Ckef0rd CaL icense No. 309031 Phone 727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELt REPLACEMENT ❑ DESTRUCTION F7 PUMP INSTALLATION El SYSTEM REPAIR %1C OTHER F1 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 I Industrial ❑ Open Bottom t I Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Y I'1 Public ❑ Other f_1 Delta Depth of Grout Seal Type of Grout Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by _ \51 n Repair Work Done XX Type of Pump 11h H.P. Sub_ State Work Done added 201 COlLm t0 p117p �1 I Well Destruction Cl Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION I I DESTRUCTION [ I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal S Distance to nearest: Well Foundation _ Property Liner LEACHING LINE 1.1 No. & Length of lines _ Total length/size FILTER BED t I Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS I I 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 regulations 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, l shall not employ any person in suc4,61anner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following• "Vcsrtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califorgf f� The applicant m f or AiII;required inspections. Complete drawing on reverse side. Signed x Tide: Bkpr. Date: 07/17/90 FOR DEPARTMENT USE ONLY Application Accepted 1: E•�� '.� Date „_. 9'0 Area /2— Pit or Grout Inspection by Date Final Inspection by �6 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201t'� 1 EE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. EH 13-241REV.liy5i EH 1 4C 626