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APPLICATION FOR PERMIT A SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., STOCKTON, CA - Telephone (209) 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 16522 S. Van Allen City.Fscalon Lot Sae PM Owner's Name G F ' Address 2-1602 Carrcd tonsRirmn Phone ContractorPLlt�TlariCe Drillers�dTa _ PO�ox 64,Linden License No. 377923 ---Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL IX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 14" Dia. of Well Casing " ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing stP_P_1 Specifications ' I'l Public F Other ❑ Delta Depth of Grout Seal Type of Grout IWlrrigation _ ,__� ___.—_Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material I8elow 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION f I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence__ Commercial— Other _ + Number of living units: Number bf bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ e �' _ y� Fi Z4.I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Y _ Total length/size \ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L-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 Di?;trict. 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "I certify 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 California." The applicant must call t r all re uir d inspections. Complete drawing on reverse side. Signed X Title: President Date: 10/14/88 F PARTMENT USE ONLY Application Accepted by V�XCrN� ��' Date ��_1^% Area 05 Pit or Grout Inspection by C Date J �f Final Inspection by Date r Additional Comments: b 7 ` a •/ / �r � ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AM DUE AMOUNT REMITTED CASH CK 11 RECEIVED ElY DATE PERMIT-NO. +.EH t324IREV.vn5l �~ / // llb-17WJ`_";�X� 00 t