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i APPLICATION FOR PERMIT SAN JOAQUIN,LOCAL HEALTH DISTRICT - Nu W C-L` 1601 E. HAZE.—J ON AVE., STOCKTON, CA y Telephone (209) 466-6781 No ti s PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Qac oLD Q i S ew c)L6 ' ( (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 ion is made in compliance with San Joaquin County Ordinaric"o.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 2965 N. .WILSON WAY •_ City -STOCKTON Lot Size PM Owner's Name JOHN NICHOLS Address 1827 ALLSTON WAY Phone . 463-1171 l ContractorYETTER PLBG. Address 1035 S. AURORA .ST. License No. 202228 Phone 463-1 06 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . NE FOUNDATION AGRICULTURE WELL OTHER WE PITSlSUMPS INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTIO ICATIONS ❑ Industrial ❑Open Bottom ❑ Manteca Di e FExcavation, Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications ❑ Public i0 Other ti Delta Depth of Grout Seal Type of Grout 1 ❑ Irrigation Fox Depth ❑ Easter-- Surface Seal Installed by t9_ i Repair Work Done frype of Pump H.P. State Work Done _ T Well Destr ' n ❑ Well Diameter Sealing Material (top 50') ' Depth s.l. FillefMate-rial-(BeI6W 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION>r(No septic system permitted if public sewer is t i available within 200 feet.) Installation will serve:- Residence_I Commercial E Other Number of living units: I Number of bedrooms;a ti At r r k Character of sotl to a depth of 3 feet ; i ` t Water table depth �1 SEPTIC TANK Type/Mfg t Capacity l800 No. Compartments c5C PKG. TREATMENT PLT. 0 Method of Disposal n Distance to nearest: *Well" " Foundatio'n Property Line LEACHING LINE ❑ No. & Length of lines ( Total length/size f I FILTER BED O Distance to nearest: Well' Foundation 1 Property Line SEEPAGE PITS Cl Depth: 4v-- <. Size 'Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Q. - +4' 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 cert that in the performance f h r - g rfY pa ce o the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California. The applicant ffAusitcall for all req fired inspections. Complete drawing on reverse side. �j PRESIDENT o Signed Title: _ g Date. F TMENT USE ONLY Application Accepted by ��+tlh�_ Date._ Area Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant 823-7104 Cf Tracy 835 6385 Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., PA. Ba 2009, Stk., CA 95201 y `� FEE AMOUNT DUEAMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO CAW + EH 13-24(REV.t i a 5) r r , EH 1436 i