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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) / y y Application is he made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is 1 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 f r: I . _ u. Local Health District � .f 2256 E. Cherokke Road _t�>.rto Lot Size — PM Job Address City Owner's Name Gloria -A.- Anson= Address P.O. Box 7011 Modesto95��5phone 524-8190 1s 463-1706 , lContracto ' t Vetter Plb .f CO. Addressl0 5 S. Aurora St. License No. 202228 Phone TYPE F WELL/PUMP: NEW WELL ❑ - WELL REPLACEMENT ❑ DES TRUCTION`S PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER ❑ DISTANCE TO NEAREST: SEP SEWER LINES DI SAL FLD. POOP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom_ ❑ Manteca Dia. o xcavation Dia. of Well Casing 1L •� ` ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications ❑ Public E] Other ❑ Delta Depth of Grout Seal 1 z Type of Grout ` N ,. 11 Irrigation J4 x. Depth '❑ Easterner, Surface Seal_lnstallsd by - zRepair Work Done `.❑ �T pe of Pump~ H.P. State Work Done ` /Well Destructiorti�iC WeII Diameter-� •w—Sealing-Material (top 50'} r / ry Depth 5 Filler Material (Below 50')'L TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is - available within 200 feet.) Installation will serve: Residence— Commercial L Other s ' Number of living units: Number of bedrooms} t i 'Character of soil to a depth of 3 feet: f _F Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments F PKG. TREATMENT PLT. v Method r of Disposal i � �'`"�� Distance to nearest: Well k 'Foundation -_.Prop erty Line LEACHING LINE ❑ No. & Length of lines Totaltlength/size !! F FILTER BED 11 Distance to nearest: . V ell - Foundation *Property Line f SEEPAGE PITS ❑ Depth Size ^ Number' rte+ SUMPS ❑ Distance to nearest: Weil -- i -3 Foundation j �F§`'Property Line DISPOSAL PONDS ❑ vj 1 . 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. _ i Home owner or licensed agent's signature certifies the following:"I certify that in'tha 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." �- r The applic must call for all required inspections. Complete drawing on reverse side. 01 /05188 "� 1 f Signed X Title: PreSC�E�lIr Date: _ ' FOA DEPART ENT USE ONLY _ I15� ` Area Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: _ ❑ Stk 466 6781 ❑i Lodi 369-3621X1 Manteca 823-71 ❑ Tracy 835-6385 i 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 CIC H RECEIVED BY DATE E;RMI INFO ,( [ �,yf AJS +EH 13-241REV.1/85) .6a 4 . " 3 ,((A EH 14-26