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APPLICATION FOR PERMIT 45. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES f YEAR FROM DATE ISSUED TV-0 VA. t (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 Local Health District. the San Joaquin -V a - Job Address . SUNNYSDIE IC City STOCKTON ' ^Y Lot Size PM Owner's Name L.Ta=RAND — Address-..1240 SUNNYSIDE V Phone 946-0741 Cor,tract,rVETTER PLBG. C0a' 'AWsr 1035 S. AURORA. ST, License No. 202228 Phone 4631706 � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump TH.P- State Work Done , Well Destruction ❑y Well diameter Sealing Material (top 50') Depth # Filler Material (Below 501 1 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 ' Character of soil to a`depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg No. Compartments PKG.TREATMENT PLT:EJ Method of Disposal Distance to nearest: Well� Foundation Property ` t party Line- ` LEACHING LINE 1 ❑ No. & Length of lines ` - - -Total length/size y FILTER BED ' EI Distance to nearest` Well Foundation ; Property Line SEEPAGE'PITS ❑ Depth Size Number 1 SUMPS LlDistance to nearest: Well Foundation . Property Line ) DISPOSAL PONDS ❑ I hereby certify that I have prepared this application andthat 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 tion laws of California." persons subject to workman's compensa- The applica ust call for allrtqu1M9jnBpections. Complete drawing on reverse side. i Signed x � Title: presidentDate: 3/18/87 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection Date Final Inspection b Date -� � ' - -Additional Comments: v 1C1.7h ❑ Stk 466-6761 ❑ Lodi 369-362P ❑ Manteca '823-7Nm ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`N0. INFO (�} ( H 1REY.t/asl EH 1426 �r-