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1 ' 2 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT -1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 0\0 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 1227 N. "E"S STREET . City STOCKTON Lot size PM Owners Name DELORES SEGURA Address 1227 N. "E"E ST. Phone 465--7F83 Contractor VETTER PLBG. CO. Address 1035 S. AURORA ST. License No. 202228 Phone463--1706 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ' PUMP INSTALLATION ❑ 1 SYSTEM REPAIR:❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK q4sWrR LINES " l DISPOSAL FLD. PROP. LINE FOUNDATION A�AR TURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLECONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open.Bottom. - . ❑ Manteca, rDia. of.-Well-Excavation-- Dia:of Well-Casing 9 ❑ Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing Specifications V ❑ Public ❑ Other ❑ Delta �Depth of Grout Sea! Type of Grout ❑ Irrigation —Approx. Depth ❑ Ea _ern ,,-x _Surface-Seal Installed by ' Repair Work Done ❑ Type of Pump H.P_ ` State Work Done E Well Destruction ❑ Well Diameter v Sealing Material (top 50'� Depth Filler'Material (Below 501 s TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION7,(No septic system permitted if public sewer is ailable within 20D feet.) Installation will serve: Residence Commercial_ Other F Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. I❑ i Method of Disposal Distance to nearest: Well Foundation k Property Line LEACHING LINE ❑ No. & Length of lines y Total length/size ` FILTER BED ❑ Distance to.nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well FoundationProperty Line DISPOSAL PONDS EDI 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. 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."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applica i st call f II r wire ins -amplete drawing on reverse side. Signed Title: PRESIDENT Date: 6/15/87 1 FO ENT USE ONLY Application Accepted by Date — Are OI Pit or Grout Inspection by Date Final Inspection b Date �r Additional Comments: ❑ Stk. 466-6761 ❑ Lodi 369-3627 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT Np. INFO 70 3-241 C{/A/SH, + EH14-2aSREv.tie5) EH 1428 i _.