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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T 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 ItNCity Lot Size PM Owner's Name _Gaylan Quelrolo Address 1011 W. ElM Stockton Phone 946 ' 0872 Contractor PurvianC'e Dz7 lleraJ . P. -O. BOX 64,LinderL,icense No. 377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ Cb 9 PUMP INST) SYSTEM REPAIR ❑ OTHER p DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESL DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' I] Industrial El Open Bottom © Manteca Dia. of Well Excavation_ 16 _- Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing f1 Y YP 9 Specifications P Public Ll Other Cl Delta Depth of Grout Seal — — Type of Grout X Irrigation 525-Approx. Depth I I Eastern Surface Seal Installed by 4 Repair Work Done ❑ Type of Pump turbine H.P. 75 State Work Done new well & pump (� Well Destruction Cl Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') i TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is t - available within 200 feet.) \ Installation will serve: Residence : Commercial_ Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet-.ti Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:- Well -Foundation '-Property Line— `x LEACHING LINE ❑' No- & Length of lines T i otal length/size f FILTER BED ❑ Distance tit nearest: Well Foundation ' Property Line 1 �.1 t SEEPAGE PITS f 1. Depth I SizeNumber SUMPS ❑ Distance toinearest: Well Foundation Property Line r DISPOSAL PONDS ❑ 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."Contractor's 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- k tion laws of California." The applicant must call I r q r inspections. Complete drawing on reverse side. Signed X Title: 'd��_ 10/14f 88 FOR EPARTINENT USE ONLY W ` t 3 Application Accepted by bate_ \ Area ' Pit or Grout Inspection by Date Final Inspection by X Date 77 Additional Comments.- 0 omments:❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 . FEE AMOUNT DUE ?: AMOUNT REMITTED CK RECEIVED 8Y DATE PERMiT�NO, v INFOAT CASIA 4 +.EH 13-21(REV,tits5) EH 11-29 �J V �U �(� �5 �.r✓S �c Sr GI 1 LA `