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1 E APPLICATION FOR PERMIT r' i SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,,STOCKTON, CA 1 >� ! Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j L - (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: 1 Job Address 1242 N. FUNSTON City STOCKTON' Lot Size - 4 PM rt Owner's Name RAYMOND SMITH Address 1242 N. FUNSTON Phone 463-8097 Contractor VETTER PLBG. CO. Address1035 S: AURORA ST. Cicense No. 202228 Phone463-1$06 l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ kPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � Dia.,of Well Excavation Dia. of Well Casing El Industrial El Open bottom, `AI I Manteca ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public [I Other ❑ Delta Lir Depth of Grout Seal Type of Grout ❑ Irrigation Approx-_Depth.. D-Eastern .Surface Seal-]nstalled�by�- Repair Work Done ❑ 'Type of Pump f, H.P. State Work Done Well Destruction E1_7 Well'Diameter-- Sealing Material Itop 50.1 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION A'No septic system permitted if public sewer is a.. .. available within 200 feet.] i ` Installation will serve: Residence Commercials Other t Number of living units: Number,of bedrooms." 'r Character of soil to adept of 3 feet: # -l-S, � Water table depth SEPTIC TANK Type/Mfg - ' a Capacity No. Compartments PKG. TREATMENT PLT. ❑ r.�A. Method of Disposal Distance to nearest: `�Well �� + Foundation' Property Line LEACHING LINE' ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance-to nearest: Well Foundation Pro Ry Line n SEEPAGE PITS Depth �� Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicat u t call far�req ire nspections. Complete drawing on reverse side. Signed x Title: PRESIDENT Date: 413/87 FOR DEPARTMENT USE ONLY i Application Accepted by Date [ Area j Pit or Grout Inspectio Y Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO �+EH 13-24 REV:, EH 14-26