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APPLICATION.FOR PERMIT ) ' SAN JOAO.UIN LOCAL HEALTH DISTRICT ^^}} 1601 E. HAZELTON AVE., STOCKTON, CA a� Telephone 12091 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 i 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. 1643 & 1.637 NEWPORT AVE& • N g • {O` Job Address city STOCKTON Lot Size PM Owner's Name ANTHONY F PELUSO Address '1643 8t"•1637NEWPORT AVE. phone 466-9200 ContractorVetter _Plbg. CO. Address 1035 S. Aurpra St. License-No. 202228 Phone 46 -•1 06" o� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE *} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE V FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS -R� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial,, ❑ Open Bottom ❑ MantecaDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy` Type of Casing Specifications i E) Public r Ll Other ❑ Delta Depth of Grout Seal Type of Grout i ❑ Irrigation _____4pprox. Depth ❑ Eastem SurfacesealInstalled by Repair Work'Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ 'Well Diameter Sealing Material ltop 50'1 1 ` Oepthl Filler Material {Qelofw•501 .F TYPE OF SEPTIC WORK:' NEW INSTALLATION O REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1; I available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms tI.,c " Character of soil to a depth of 3 feet: - " y ' Water table depth SEPTIC:TANK Type/Mfg O f L2,6apacity 1 No. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal Distance to nearesIV.--� Welles Foundation"` Property Line LEACHING LINE ❑ Nod& Len th of lines" i T k g Total length/size f FILTER BED ❑ Distance to nearest._. 1 Well Foundation- 1 Property Line SEEPAGE PITS �Q Depth Size Number T " SUMPS El 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:,District: � V_ `� ' k Home owner pr 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 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." 1 The applica i must call for all "re fired inspections. Complete drawing on reverse side. Signed X (: Title:PRESIDENT + Date: 4/10/87 FOR DEPARTAAENT USE ONLY s Cr Application Accepted by �} Date Area [ f Pit or Grout Inspection by. Date Final Inspection byf/ll Date / Additional Comments, ❑ Stk 466-B781 Lodi 369-3621 ❑ Monte 823-7104 ❑ Tracy 55-6385 f- Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK ID i RECEIVED BY DATErc-��` PERMIT NO. 4 t EH 13-24(REV,1/857 `�5 . F' +��'7 i —,U 5-a- �'� I EH 1429 Y