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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone 12091 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 wellipump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 15209 5th Streat City Lathrop Lot Size PM Owner's Name ;sabal Tabaugcura Address 15209 5th St., LathroP Phone 85$'26'00 Contractor Vallejo Const. 1E111G. Address 1290V llrs Q t.malL License No.479838 Phone 982-5661 TYPE OF WELL/PUMA: 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 L1Gravel Pack ❑ Tracy Type of Casing Specifications * Public Cl Other Cl Delta Depth of Grout Seal Type of Grout t.+ I I Irrigation --Approx. Depth I I Eastern Surface Seal installed by - IND Repair Work Done ❑ Type of Pump H,P. State Work Done _ �D Well Destruction ❑ Well Diameter Sealing Material (top 50') rt Depth Filler Material (Below 501 W TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION t 1 DESTRUCTION 1 (No septic system permitted if public sewer is to available within 200 feet.) rt r! Installation will serve: Residence X Commercial_ Other p Number of living units: 1 Number of bedrooms R Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Cement Capacity t31R)SnoWn No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal 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 fl b SEEPAGE PITS I I Depth Size Number 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 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." The applicankmust call f�or�allrequiredinspections. Complete drawing on reverse side. Signed X ,x/ ^�LY�� Title: Estimator Date: 9/187 Application Accepted by FOR DEPARTMENT USE ONLY Date Area 13 IA6Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: �u �� - -- ❑ Stk 466-6781 ❑ 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 CK RECEIVED BY DATE PERMIT-NO. INFO CASH ♦ EH 13.24 1REV.t i H s] 3.S EH 14-26