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i!.11 APPLICATION FOR PERM, !- SAN J ' : SG.N JOA L;!; LOCAL Ht LTH i5TR1CT 61U, i 1601 E. HAZELTON AVE., STOCKTON, CA PERMIT N0. 17 �� f ' , Telephone (209) 466-6781 /1J��WyPERMIT EXPIRES I YEAR FROM DATE ISSUED SAN .�OPQUIO' 'L.(DC,.TL ISSUED �! S-.5ir (Complete in Triplicate) HEALTH ['►iSTR10_T 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. t862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address .1.7-84W- N. HWY. 88 Subdivision Name, Owner's Name KEMALYAN & LARSON AddreJ?.O,Box 7041, Stockton, Ca . Phone Contractor's Name Goehring Pump License No. 309031 Phone 727--5548 TYPE OF WELL/PUMP WORK: NEW WELL WELL REPLACEMENT E] DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER C4 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FEB. PROP. LINE. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation ❑ Domestic/Private ❑Gravel Pack L]Tracy Dia. of Well Casing ❑ Public ❑Other ❑Del to T Dp irrigation Type of Casing C] 9 Approx. ❑ Eastern I ❑ Specifications Cathodic Protection Depth r Geophysical Depth of Grout Seal Other Type of Grout Surface Seal Installed by Repair Work Done ) Type of Pump sub. H.P. 3 State Work 00neMpLafpd01 C3 t-tirhi ne Well Destruction ❑ Well Diameter Sealing Material (top 501) u Depth Filler Material (Below 50') I TYPE OF SEPTIC WORK: NEW INSTALLATION I-1 REPAIR/ADDIT,ION LJ. (No septic tank or seepage pit permitted if public sewer is available 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: Water table depth SEPTIC TANK �f Type/Mfg Capacity No, Compartments PKG. TREATMENT 'PLT. [] Type/Mfg Capacity`' Method of Disposal SEWAGE SYSTEMDistance to nearest: Well Foundation ._' Property Line DESTRUCTION ❑ LEACHING LINE jJ No. S Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS l-1 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 f ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. , Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I sh l 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.-Aich this permit is shall employ persons subject to workman's compensation laws of California." The applicant m fo 11 required inspections. Complete drawing on reverse side. Signed X ! Title: Bk r. Date: 1 n In /R4 Application Accepted by Area _ Q� Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspettion..by Date Manteca 823-7104 final Inspection by �:s-� Date - Y�❑ Tracy 835-6385 Applicant - Return all copie to: Environmental Health Permit/Services 1601 E, Hazelton Av P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFOLis C, , I EH 13-24 REV. 10/82 .10/82 500 14-26