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APPLICATION FOR PERMIT SAN JOAQU:IN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE.,-STOCKTON, CA I Telephone (209) 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 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. e Job Address 830 ELLENCi o . _ ty � Lot Size PM 83-�7_ Owner's Name IRA F.ELKINS ,' .. _ Address - -814, la:I.LEN Phone 463-7897 Contractor VETTER PLBG. CO. Addre,00 5 Z. AURORA ST. License No. 202228Phone463-1706 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTAN PTIC TANK SEWER LINES DISPOSAL FLD, INE FOUNDATi AGRICULTURE WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM RUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ ate% `.,,. _Dior o_Y w tion. Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pa ❑ Tracy Type of Casing Specifications ❑ Public ❑ er ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _ �4pprox._Depth EJ Eastern__ ,Y�Su face.5 IInstalled by... Repair Wor ne ❑ Type of Pump i H.P. State Work Done E r We struction ❑ Well Diameter I Sealing Material (top 50') I t t a Depth i Filler Materia1-(13elow-501 ---- TYPE OF SEPTIC WORK: NEW INSTALLATION L1REPAIR/ADDITION LJDESTRUCTION (No septic system permitted if public sewer is 1 available:within 200 feet.) i Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg "C t o . 1" Capacity f No!Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line { I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS ❑ Depth . Size Number 1 SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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." The applicant call for all re[q�uir d ins tions. Complete drawing on reverse side. Signed X � � Title: PRESIDENT Date: 4/14/87 FOR DEPARTMENT USE ONLY c^� Application Accepted by Date — �J Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: —:501116 Qef 1 f ! e El Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante& 8234104 ❑ racy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO J}�iAMOUNT DUE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT•NO. + EH 13-24(REV.1/H 57 EH 14-28