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APPLICATION FOR PERMIT n b tt ,�•4 '^'� SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 L PERMIT EXPIRES TYEAR 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 14684 Avon City Lathrop Lot Size 1 acre PM Owner's Name Sabina Menor Address 14684 Avon, Lathrop Phone 983-0166 11290 Vallejo Ct. Contractor Vallejo Const. Inc• Address French Camp, CA 9523W- e e%No-479838 - Phone 982-5661 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-R/',j,`, DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAID–R'n --�–. 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 ElIndustrial I4" E'n,`Q 6n Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing N f r ElDomestic/Private;.. Gravel Pack ElTracy Type of Casing Specifications M Public n Other F1 Delta Depth of Grout Seal s Typ -of, Grout _ P+ I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work;; Done_ t0 . Well Destruction ❑ Well Diameter Sealing Material (top 501 f Depth E Filler Material (Below 501 G TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTIONXX (No septic system permitted if public sewer is ¢ available within 200 feet.) Installation will serve: Residence X Commercial_ Other Numberlof living units: 2 Number of bedrooms y Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg Cement Capacity ulnknoWn No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING,LINE ClNo. & Length of lines Total length/size FILTER BED. ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health District. P I 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:'fGrontractor'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 applicantust call for all required inspections. Complete drawing on reverse side. Estimator 10/6/87 Signed X Title: Date: .r `�'.SFOTM T�USE ONLY , - " ,, Application Accepted by Date ' Area` 3 Pit or Grout Inspection byDate �; ._ -Final Inspection by i i DatQ/� Additional Comments: �I"�y f IDU-S _Pl(-m 1 � "4...„ El '835-63195' Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tricy 835-63 v' 95 V 1 1 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 �7 3 + EH 13-24(REV.t/H 5) �•� 10-7-97 9/ " 37 EH 14-26 L /