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a APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE., S,TOCKTON, CA : Telephone 1209! 466-6781 w- PERMIT EXPIRES .1 YEAR FROM DATE ISSUED f (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. 1852 for well/pump and the Rules and Regulations of the San Joaquin Local Health District.,>, 3752 SECTION AVE: STOCKTON Job Address _ City Lot Size PM_ Owner's Name'MARY-'TITSWORTH Address 3752 SECTION AVE Phone948-3526 Contractor VETTER PLBG. CO. Address 1 035 S. AURORA ST. License No. 202228 Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELLREPLACEMENT(O `DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK_ _ SEWER_LINES DISPOSAL,FLD. .PROP. LINE. FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS, 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 i ❑ Delta Depth-of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern . Surface Seal Installed by Repair Work Done ❑ Type of Pump o. H.P. r r'gtate Work Done Well Destruction ❑ Well Diameter } Sealing Materiall(top 501_. Depth •---filler-Material (Below 50') ti TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONNo septic system permitted if public sewer is 1 1 available within 200 feet.) Installation will serve: Residence Commercial! Other z Number of living units: Number of bedrooms 1 t ! Character of soil to a depth of 3 feet ' ' Water tableidepttr SEPTIC TANK ❑ Type/Mf j Capacity No. Compartments' PKG. TREATMENT PLT. ❑ Method of Disposal Distance''.to nearest: Well Foundation Property Line I # i 14r LEACHING LINE ❑ No. & Length of lines Total length/size 1 j FILTER BED ❑ Distance to nearest: .t Wel Foundation Property Line j � f 9 SEEPAGE PITS ❑ Depth I Size Number f SUMPS ❑ Distance`to nearest: E.--Well- 'Foundation Property Line ` DISPOSAL PONDS ❑ �`e�. 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 i 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." I The applic t ust call f all requ'r I S. Complete drawing on reverse side. Signed x Title: PRESIDENT Date: 5/19/87 t FOR DEPARTMENT USE ONLY I Application Accepted by Dates— r Area a. Pit or Grout Inspection by f Date Final Inspection by Additional Comments: ` �J _? _ ❑ Stk 466-6781 .. ❑ Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354MM Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 lFEEO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. + EH 14-241REV.t/s51 f � l� _ �� {/ � 9-7 q:?3 EH 10.28 Q �^i�1