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APPLICATION FOR PERMIT rt SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 'I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the Son 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";'� ,t Job Address 1637 HIAWATHA City STOCKTON Lot Size PM Owner's Name DOUGLAS WHITE- - Address 1637 HIAWATHA Phone948--1434 ContractorVETTER PLBG. CO.INQdress 1035, Se AURORA ST License No. 202228 Phone 463-1706 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI ES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULT E WEL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C N RUCTION SPECIFICATIONS I ❑ Industrial ❑ Open Bottom ❑ Manteca Di of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe f Casing Specifications ❑ Public ❑ Other ❑ Delta Depth o rout Seat Type of Grout ❑ Irrigation ---Approx. Depth ❑ Ea§tern 'Surface"Seal Installed,by r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Materia! (top 50') k ► Depth Filler Material (Below 501 t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is' " ` vailable within 200 feet.). Installation will serve: Residence_ Commercial Other, #€ " Number of living units: Number of bedrooms w �x Character of soil to a depth of 3 feet: Water table'depth'% t SEPTIC TAMC ❑ Type/Mfg Capacity 1 No. Compartments^ PKG. TREATMENT PLT. ❑ ; Method of Disposal, Distance to nearest: well f Foundation Property Line f•' LEACHING LINE ❑ No. & Length of lines `"` Total length' /size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SL MPS ---T__1_Distance to nearestf7�Well""" FoundaEio "Property Cine— DISPOSAL PONDS ❑ 1 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. ,, a 4 Home owner or licensed agent's signature certifies the-following: 'xi 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 compensatipn laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certifythat 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 applicant st call for all required inspections. Complete drawing on reverse side. a 4 Signed X Title: PRESIDENT T �xDateWIMU FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspecti !!33 Date Final Inspection by 1 Date Additional Comments: '`V(Ls arm f 17Z_5) ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83543M v ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 ti' FEEAMOUNT DUE AMOUNT REMITTED, C51M RECEIVED BY DATE RMIT'NO. (� �� PE r EH 14-26(REV. /651 - 35. 10 CJ p i ��\ �1 o/ IT-7--xqT4J .