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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 r' L in 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. Job Address 16021 Eton Way City Lathrop Lot Size PM Owner's Name Alejandro Barilla �ds16021 Eton Wy , Lathrop Phone $58-2270 �� a e oCt. Contractor Vallejo Const, Inc. Address French Catnip, CA 95231 License. No. 479838 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 FLO. 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications n Public ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout I I irrigation _..Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction C1 Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I i DESTRUCTION I*(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_X__ Commercial_ Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t,, SEPTIC TANK ❑ Type/Mfg @S9nt Capacity nn tlOt,11n No. Compartments O PKG. TREATMENT PLT. ❑ Method of Disposal r Distance to nearest: Well Foundation Property Line M rr O LEACHING LINE ❑ No. & Length of lines Total length/size R FILTER BED ❑ Distance to nearest: Well Foundation Property Line m �d SEEPAGE PITS l 1 Depth Size _ Number " SUMPS 0 Distance to nearest: Well Foundation Property tine DISPOSAL PONDS 1=1 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 b 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 persons subject to workman's compensa- tion laws of California." Theapplic nt m st call for all required inspections. Complete drawing on reverse side. Signed X Title: Estimator Date. 9/11/87 A FOR DEPARTMENT USE ONLY Application Accepted by �lf— 4cj,\ Date „t�� Area 13/ 3 Pit or Grout Inspection by Date Final Inspection by Additional Comment-_2 zl}92AA,,,,-91X ❑ Stk 466-6781 ❑ Lof i 369-3621 O Manteca 3-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT*No. + EH 13-241REV.1/x5) L' le— EH 14-2e / Q