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a <br /> I <br /> 1 APPLICATION FOR PERMIT <br /> f SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> 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 <br /> Local Health District. <br /> Job Address 1528 WILLIAMS ST. <br /> City STOGKTON Lot size <br /> PM <br /> Owner's Name EARL CATHCART Address 14201 N. JA K ONE RD s-LOW Phone 466--0414 <br /> Contractor VETTER PT.R(' (°{)_�Ness <br /> License N. _.207908 phone — <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FDD. PROP. LINE <br /> FOUNDATION AGR LTURE WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON RUCTION SPECIRCATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca i . of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy of Casing Specifications <br /> ❑ Public ❑ Other ❑ O 'Ito Dep of Grout Seal <br /> ❑ Irrigation Type of Grout <br /> g —Approx. Depth ❑ Eastern Surface al Installed by <br /> Repair Work Done ❑ Type of Pump State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') a <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.),-- <br /> Installation will serve: Residence— Commercial_ Other ! <br /> r <br /> Number of living units: Number of bedrooms .. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/MfgCapacity No. Compartments !� <br /> PKG. TREATMENT PLT. [I -� <br /> Method of Disposals � <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FiLTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size w Number <br /> SUMPS ❑ Distance to nearest: Well g <br /> DISPOSAL PONDS <br /> Foundation Property Line <br /> ❑ s c.q,_ �, <br /> 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 <br /> rules and regulations of the San Joaquin Local Health•District. o <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." r. <br /> The applicant must call for all required inspections. Complete drawing on reverse side. y <br /> Signed _ Title: PRESIDENT Date: 8/10/87 <br /> FOR QEPARTMENT USE ONLY <br /> Application Accepted by 4 Date Area <br /> Pit or Grout Inspection y Date <br /> Final I`s coon by Date <br /> Additional Comments: <br /> C r t J _ <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 C f - <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r f <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE ;PERMlT`NO. <br /> i EH 13-14 MEV.I/B 5) <br /> EH 14-28 ��0 <br />