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I r� APPLICATION FOR PERMIT rill SAN JOAQUIN LOCAL HEALTH DISTRICT xe 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is heldby made to,the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TNs application is I" made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weHipump and the Rules and Regulations of the San Joaquin 1 Local Health District. Job Address 15804 Cat»brid a City Lathy Lot sire 100 t X IAO' PM Owner's Name Ban ""&to Address _15804 Cambridge, L&tbrop Phone 982-506 11290 Vallejo Ct- Contractor Vallejo Confit. ZVC Address Preach Ca", C& 9523License No. 479838- —Phone 082-5661 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 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 D Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications I'1 Public Cl Other CI Delta Depth of Grout Seal Type of Grout — I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done -❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIWADDITION l I DESTRUCTIONXI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial._ Other Number of living units: 1 Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Clement Capacity Unknown No. Compartments a PKG. TREATMENT PLT. ❑ Method of Disposal C Distance to nearest: Well Foundation Property Line -P LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 171 Distance to nearest: Well Foundation Property Line G t1G SEEPAGE PITS I'Ii Depth Size _ Number 8 SUMPS ❑: Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑. 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 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 F 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." ! t The applicant m st call for all required inspections. Complete drawing on reverse side. Signed X Title: Estimator Date: 9/2/87 FOR DEPARTMENT USE ONLY Application Accepted by Date + `- Area 13 Pit or Grout Inspection by� Date Final Inspection by DateOf Additional CommenK �3621�D ❑ Stk 466-6781 t `❑Lodi 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO + EH 13.24 1 REV,1/8 51 � Vp7�" `7 EH 14-2$ ttt.J�N�// - a