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+ APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA n L rt Telephone (209) 466-6781 PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is he+eby 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 166 Shilling Avg. ..city LathrDp Lot Size PM I I _ Owner's Name Vicente ReAaCho Address 166 Shilling Ve., Lathrop Phone none 11290 Vallejo Ct. Contractor Vallejo COnSt. IiIC. _Address French CAM. CA License No.479838 Phone982-5661 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O 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—Q-:Open-Bottom .—❑,Manteca .---—Dia-:-of-Well ExcavationDia:of`Well-Casing----- r, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 Public ❑ Other n Delta Depth of Grout Seal T ICA _ p Type of Grout _ I I Irrigation _-Approxi Depth I I Eastern Surface Seal Installed by 'r r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction Cl Well Diameter Sealing Material (top 50'1 t"`' p Depth 1 Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION I DESTRUCTIONXX {No septic system permitted if public sewer is C #} available within 200 feet.) tD Installation will serve: Residence E1' Commercial'_ Other Number of living units: 1 Number of bedrooms Character of soil to a depth of 3 feet; Water table depth SEPTIC TANK N Type/Mfg " Ce=nt Capacity—A ilikPOWR No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal r3 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 SEEPAGE PITS I 1 Depth I Size Number SUMPS D Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i v 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. 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." Contractor's hiring or sub-contracting signature certifies the following: 1 certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." 1 The appli must call for all required inspections. Complete drawing on reverse side. Signed Title: Estimator Date:+10/15/87- -- --.. EPARTMF_ls1F USErONLY Application Accepted by 4. QAII --= +nn�f M Date tQ^ ':.0 Area 13 / 7 Pit or Grout Inspection by Data Final Inspection by Date7 Additional Comments: r ❑-Stk, 466-6761 ❑ Lodi 369-3621'f-' ❑ Manleca _1123=7104---Ef Tracy 835-6385"-'' 'Applicant=Return all copies to:Environmental Health Permit/Sefvices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO f AMOUNT DUE AMOUNT REMITTED CASH CK 4s -'`RECEIVED'6Y DATE PERMIT-NO. EH 13- EV.1/95) :o� EH lI-A Ze