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- APPLICATION FOR PERMIT �\ SAN JOAQUIN LOCAL HEALTH DISTRICT " L " 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone {209} 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 1662 for wellipump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 16022 Cambridge City Lathrop Lot Size 70' x 120' PM Marls: Peacher ddre s 16022 Cambridge, Lathrop Phone 858-2475 Owner's Name 11290 Vallejo Ct. " Contractor Vallejo Const. Inc. Address French Camp, CA License No.4798$ Phone 982-5661 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 ElDomestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications l'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done LJType 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 {.l REPAIR/ADDITION 1.1, DESTRUCTION INo septic system permitted if public sewer is i --available within 200 feet.I Installation will serve: Residence_ Commercial_ Other j; Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments N PKG. TREATMENT PLT. ❑ Method of Disposal N Distance to nearest: Well Foundation Property Line Is g LEACHING LINE ❑ No. & Length of lines Total length/size Pt I FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ W t SEEPAGE PITS F I Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ C+ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not G A employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature ry 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." Theapplican must call for all required inspections. Complete drawing on reverse side. Signed X Title: Dater 94/87 TMENT USE ONLY Application Accepted by Date .Area 13 - 7 . Pit or Grout Inspection by Date Final inspection by Date _f_ Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ 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. F INFO r + EH t3-24IREV."r/K5) F EH 14.28 .. ..//// ` v .