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APPLICATION FOR PERMIT RECEIVED SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA JUN Z 0 19M Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH {Complete in Triplicate) PERMIT/SERVICES 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 19790 Dustin Rd. City Lot Size PM Owner's Name Victor ROff Address 19790 Dustin Rd. , Acampo _ Phone 17754 N. Hwy. 88 Contractor GQe ri0Q PUMP --_Address E ockeford, Ca. License No. 30903 Phone _727-5548 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM-REPAIR 10( '�`OTf9ER'❑' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD" PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G7 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private Irl Gravel Pack ❑ Tracy Type of Casing Specifications FI Public f] Other (-I Delta Depth of Grout Seal Type of Grout I 1 Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done )QX Type of Pump SUE] H.P. 5 State Work Done pill 1 ed pump to Change Well Destruction ❑ Well Diameter Sealing Material (top 50') motor Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I 1 INo 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 -- — is a Ce o nearest: - We11 —�Fbu�atlon `Property Cine LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line ` DISPOSAL PONDS F 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 a ant's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in s manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the follow( 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 Cali The applicant for I required inspections. Complete drawing on rev�e de. Signed X Title: s{U Date: FOR DEPARTMENT USE ONLY Application Accepted by "5, Date cio Area i01"L Pit or Grout Inspection by Date Final Inspection by Date e� Additional Comments: ❑ Stk 466-67B1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH" RECEIVED By- DATE PERMIT''^;O_ — - ♦ EH t3-24 1REV.s/H S) 36: EH 14.26 0 6O_151t_ql