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APPLICATION FOR PERMIT _- SAN JOAQUIN LOCAL HEALTH DISTRICT J 1601 E. HAZELTON AVE.; STOCKTON, CA Telephone (209) 466-6781 t F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k _ v (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 1 r` 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 2366 N. FUNSTONC;ty STOCKTON Lot Size PM Owner's Name ESTHER VALLEJO Address 2366 N. FINSTON Phone 948—5114 Contra ctorVETTER PLBG. CO. Address 1035 S. AURORA ST. License No. 202228 Phone 463--1706 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ E DISTANCE TO NEAREST: SEPTICITANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS t i INTENDED USE TYPE OF_WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well-Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑4elta Depth of Grout Seal Type of Grout i El Irrigation �pprox. Depth O Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump 'q H.P. State Work Done Well Destruction ❑ Well Diameter i,Sealing Material (top 501 {Ii Depth Filler.Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION No septic system permitted'if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other/ Number of living units: Number of bedrooms F Character of soil to a depth of 3 feet: {'' Water table depth _ SEPTIC TANK ❑ Type/Mfg tt Capacity No. Compartments *` PKG. TREATMENT PLT. ❑ .i' k Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. &.Length of lines Total length/size k FILTER BED ❑ Distance to neare"st: Well 1 Foundation Property Line SEEPAGE PITS ❑ Depths Size Number . SUMPS ❑T Distance tonearest:_. Wellr, Foundation Property Line 14 — DISPOSAL PONDS ❑ ' i 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."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 applican t call for 11 qui d ' tions. Complete drawing on reverse side. Signed X Title: PRESIDENT Date: 5215/87 FOR DEPARTMENT USE ONLY t Application Accepted by / t { �� Date ! r Area Pit or Grout Inspection by r Date 1Final Inspection by Additional Comments: fff r- ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 83546385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. i n _ + EH 13.241REV.i/857 1-37 [ — �p 1&7-111,] EH 1428 1 n.