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k. APPLICATION,.FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.,-STOCKTON, CA Telephone (209) 466-6781 0,'`1 �� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate), W I 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. ; Job Address 5644 Hobart, a Stockton City Lot Size M1 PM Owner's Name Alvin Winchell -- 13388 Refuke Rd. , Galt Phone 748-2276 "5 Address Contractor Williams Plumbing Co.Address 2360 N. Wilson Way License No 289293 C16Phone 466-4004 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLD. PROP. LINE - 1 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1-1Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ( h i ❑ Irrigation ---Approx..Depth ❑ Eastern Surface Seal Installed by "\ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.h Installation will serve: Residence_ Commercial_ Other I Number of living units: Number of bedrooms ; Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well _ Foundation Property Line'— LEACHING ineLEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to`nearest: Well Foundation - Property Line 3 j SEEPAGE PITS ❑ Depth Size Number SUMPS - ❑ Distance to nearest: Well Foundation Property Line "DISPOSAL PONDS ❑ r ( ! 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 J 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 rj tion laws of California." - I The applicant m st call for a squired inspections. Complete drawing on reverse side. a n �. Signed F Title: Date: _ �+3u / ' FOR EPARTMENT USE ONLY ++{ �7 ' Application Accepted by Y. Date 1 1— 30 / Area Pit or Grout Inspection by Date Final Inspection by. v Date ! S r e Additional Comments: �'' ° aF r ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ 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 95201FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CASHI s RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.I/a s) M��f EH 14-28 ! .�-, 3S