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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT I 1601 E. HAZE T ON AVE., STOCKTON, CA L� Telephone (2091 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) /or install the work , This cation is madeincompliance wreby ithdSano the Joaqu JoJoaquin aquin County Ordinalncfe Nth District for a o.549 for sewage or 1t to No. 1862 for well/pump and the Rules and IR Regulations of the San Joaquin Local Health District. 154.91 5th Street City Lathrop Lot Size PM Job Address Owner's Name Address Phone Harold Maxwell 15491 5th St., Lathrop 858-4447 Vallejo Const. Inc. 11290 Vallejo Ct., Fr. License No.479838 Phone 982-5661 Contractor Address 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 Dia. of Well Excavation Dia. of Well Casing © Industrial ❑ Open Bottom ❑ Manteca ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION {1 REPAIR/ADDITION i I DESTRUCTION3k I (Nosb ttic system m permitted if public sewer is avaInstallation will serve: Residence E Commercial_ Other Number of living units: 1 Number of bedrooms Character of sail to a depth of 3 feet: Water table depth T SEPTIC TANK ❑ Type/Mfg Cement Capacity un own No. Compartments PKG. TREATMENT PLT. El Method of Disposal f n Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER SED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 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 parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 90 certifies the following: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- tion laws of California." —4 The appficanvinust call tgr all required inspections. Complete drawing on reverse side. Signed X Title: Estimator Date: $�24�87 FOR DEPARTMENT USE ONLY �7 �j Application Accepted by OV �" `�"�'— Date �d` Area V Pit or Grout Inspection by Date Final Inspection by DateA� fl Additional Comments: ❑ 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 CK FEE AMOUNT DUE AMOUNT REMITTED CAS H RECEIVED BY DATE PERMIT N0. INFO r EH 13-24(REV.1/"5) EH 14-28