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i APPLICATION FOR PERMIT n L rt SAN JOAQUIN LOCAL HEALTH DISTRICT 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 15490 5th Street City LathroR Lot Size S-- 1,547/ 0/ PIM P.O. Box 276 Owner's Name -Vester COX Address 15490 5th St t r0 Phone 858-228 11290 Vallejo Ct. ContractarVOJAJO C9nitt. Inc. Address French Ca 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 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 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications m Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth l I Eastern Surface Seal Installed by %0 Repair Work Done ❑ Type of Pump } H. `{� i State Work Done Well Destruction ❑ Well Diameter eamg aerial {top 50') Depth Filler,Material (Below 5011 • vs TYPE OF SEPTIC WORK: NEW INSTALLATION i l REPAIR/ADDITION I I DESTRUCTION X INo septic system permitted if public sewer is rt M t available within 200 feet.) Installation will serve: Residence 8 Commercial_ Other 1 n Number of living units: 1 Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ' SEPTIC TANK LL] Type/Mfg CeMOnt Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well Foundation Property Line y LEACHING LINE ❑ No. & Length of liner. O .q FILTER BED LJ Distance length/size Distance to nearest: Well Foundation Property Line I � SEEPAGE PITS I 1 Depth I Size Number SUMPS Ll Distance tp nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ___ I hereby certify that t 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 parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "4 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 applic mu call for all required inspections. Complete drawing on reverse side. Signed X Title: Estimator Date:9/28/87 FOR DEPARTMENT USE ONLY 13 Application Accepted by Date Area / �c Pit or Grout Inspection.by� �Da et - final Inspet:ti no by.. Date/ AdditionalomC mems: �y ❑ 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— yCK, RMW INFO CAS 1� RECEIVED BY DATE PERMIT-NO. EH t4-2tS r