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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ¢ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> 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 <br /> Local Health District. a I <br /> Job Address <br /> 805 S. DEL MAR City STOCKTON Lot Size PM <br /> Owner's Name <br /> TED BUSTILLOS Address 805 S. DEL MAR Phone 462-291 <br /> $ <br /> contractor VETTER LBG. CO A� <br /> 10 S. A RA %` wse No. 202228 _Phone 16" —1 � <br /> TYPE OF WELL/PUMP: NEW WELL 71WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION,❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:' SEPTIC TANK <br /> SEWER LINES ¢- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPEOFWELL i PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El Industrial 'EJ Open Bottom ❑ Manteca Dia. of Well Excavation V' 1 <br /> Specifications <br /> Type of Casing <br /> —, <br /> El Domestic/Private ❑ Gravel Pack 1. <br /> ❑ Tracy YP 9 <br /> El Public L1 Other 2 Delta Depth of Grout Seal j Type of Grout ! <br /> l ---Approx. Depth El Eastern <br /> Surface Seal Installed by <br /> State Work Odne <br /> ❑ Irrigation <br /> Repair Work Done ❑ Type of Pump , <br /> ealin <br /> Well Destruction ❑ Well Diameter S9 Material Itop 50"i; , <br /> Depth Filler Material-l8elow-50'1" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTS N iNailable�+crvlthin 200 feeted if public sewer is M <br /> Installation will serve: Residence= Commercial Other 'l 1 <br /> j Number of living units: Number of bedrooms Water table depth <br /> • Character of soil to a depth of 3 feet: N.G. Compartments <br />! i SEPTIC TANK ElType/Mfg ! Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> 3 f <br /> -r— Total length/size <br /> LEACHING LINE C] No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 <br /> rules and regulations of the San Joaquin Local Health District. <br /> 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, f shall not <br /> :+ <br /> employ any parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> 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 <br /> f tion laws of California." <br /> The applicant mus-call for all re uired 1 pe Complete drawing on reverse side. <br /> 4 Title: Date: .? <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> jDate _ Area <br /> fl Application Accepted by << r <br /> Pit or Grout Inspection b <br /> _ Date Final Inspection,by ate <br /> • Additional Comments: " <br /> ❑ Stk 466-6781 - ❑ Lodi 369-3621 ❑ Manteca 8x3-7104 ❑ Tracy 8354085 <br /> 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services <br /> } <br /> FEE CK RECEIVED 8Y DATE nPERMIT'NO.INFO AMOUNT DUE AMOUNT REMITTED CASH f/r��+ EH 1324{REV.7/851 "c�� `l � <br /> EH 14-26 <br />