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yF APPLICATION FOR PERMIT rtLrt Y x f SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA k 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. i Job Address 15928 S. Derby Large City—LothroD Lot Size 100 x7Q�_ PM Owner's Name Jose Mora Address 15928 S. DArbj►L. I a�Qp Phone III 11290 Vallejo Ct. I Contractor Valla, 0 COASt. IAC. Address French CAM 0 CA 9523 License No.X838 _Phone 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 USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial E1 Open Bottom ID Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation —..Approx. Depth I 1 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 I 1 REPAIR/ADDITION I I DESTRUCTIONXI(No septic system permitted if public sewer is Installation will serve: Residence� Commercial_ Other available within 200 feet. r Number of living units: 1 Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Cement Capacity11tA1VCttlOtil[l No. Compartments PKG. TREATMENT PLT. ❑ Method of Di M sposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS [ I' Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation DISPOSAL PONDS Property Line 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ tion laws of California." R Y Persons subject to workman's compensa- tion The applicant/must call for all required inspections. Complete drawing on'reverse side. Signed X �` Title: IKSt LoatOr Date: 9/l/87 FOR DEPARTMENT USE ONLY Application Accepted by Date-7 I- Area Pit or Grout Inspection _ Date Final Inspection by Dat Additional Comments 1:1Stk 466-6781 ir_ 369.3621 1:1Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copi : Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GK INFO CASH RECEIVED BY DATE PERMIT'NO. + EH 13.241REV.t/As) EH 14-2e