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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Tekephone (209) 466-6781 t: 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. 1: ..r .r�:. �Y °°k0 ., il' .-i i Job Address 1636 N. FILBERT "AVE- ;"....._' ` ` city Lot size PM Owner's'NameANTONTn O T PELUSAddress 16 6 N FILBERT AVE: _ - Phone 466-9200 Contractor J.fR!T!Q!ER. PIRG- CO—Address License'No. 202225 `� Phone46 —1 O6 i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-❑ }DESTRUCTION ❑ 1) PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ I OTHER ❑ 'i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I fOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE [TYPE-OF-WEL:C— �PROBEEM AREA t-NSTRUCTION SPECIFICATIONS_ �T ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of fWell Excavation Dia. of Well Casing 171 Domestic/Private a Gravel Pack El Tracy Type ofCasingf. Specifications ' ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ irrigation L—Approx. Depth ❑ EasternSurface Seal Installed by '« Repair Work Done ElType of Pump H.P. � 11-Stafe-'Work Done'+ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material ISelow 501 TYPE OF SEPTIC WORK: I NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is J vailable- within 200 feet.I Installation will serve: Residence— Commercial_ Other I. , l Number of living units: Number of bedrooms l r f Character of soil to a depth of 3 feet: = F_ Water table_tlepth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation k Property Line k k LEACHING LINE ❑ No. & Length of lines y Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ) l � SEEPAGE PITS ❑ Depth Sizer . _ Number ) I 1 ; rl SUMPS C1 Distance to nearest: r Well --•--�--Foundation--•-�= -�--•-Property Line• DISPOSAL PONDS ❑ r t ' 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I terrify 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." g The applicant st call fo all req u d spections. Complete drawing on reverse side. t Signed X Title:' PRESIDENT Date: 4/10/87 h� FOR DEPARTMENT USE ONLY Application Accepted by i\J�V��, Date Area y pP P / Pit or Grout Inspection by Date Final Inspection by ` Date • " Additional Comments: } f V7 ❑ Stk 466-6781 ❑ Lodi -3621 ❑ M n eta 823-7104 ❑ Tracy 835-6385 T Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO ,y�//�'A�MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PEE�RMIT'`NO.O. +EH 13-24(REV.)/85i r �� - � [�ZI Y�1�..+' I"'" L+ 1 EH 14-26 1_ l