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APPLICATION FOR PERMIT N0W SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 ,, L „ f 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 267 & 275 Shilling Ave. City.Lathrop Lot Size100' x 228' PM 1366 Wimbledon Owners Name Violet Gofatein Address Manteca, CA 95336 _ Phone 23 -3 10 11290 Vallejo Ct. Contractor Vallejo Coast. Inc r Address French Camp, 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 WEA!_. -_P_{ S./SlJN1PS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t?`� + ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation d Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications .T ❑ Public ❑ Other F ❑ Delta Depth of Grout Seal + Type of Grout ~° I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by— r Q' Repair Work Done ❑ Type of Pump H,P. State Work Done V Well Destruction El Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 501 I TYPE OF SEPTIC WORK: NEW INSTALLATION 11, REPAIR/ADDITION I I DESTALITION R4 Md septic system permitted if 'ublic sewer is �µ.+ Installation will serve: Residence Commercial Other r_ A. �v a le withinr200 feet.) Q x{ w Number of living units: 2 Number of bedrooms OQ Character of soil to a depth of 3 feet? � t Water table depth SEPTIC TANK XV7 TypelMfg Cent Capacity unkno4n No. Compartments PKG. TREATMENT PLT. 0 ? Method of Disposal Distance to nearest: Well Foundation! Property Line LEACHING LINE —P—No--&-L-ength-of-lines Total length/size t FILTER BED ❑ Distance to nearest: Well iFoundatiog Property Line Iq SEEPAGE PITS i I Depth a Size t l Humbler ! SUMPS ( Cl Distance to nearest: Well )Foundation i Property Line DISPOSAL PONDS ❑ I hereby certify tliat 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: "1 certiN 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 compensatiol+.laws of California."Contractors hiring or sub-contracting sigria'ture certifies the follo%king: "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." tT'�' The applicant ust call for all required inspections. Complete drawing on reverse sine. _ 1 i11 Signed x _..- Title: 'Estimator Date: 10/15/87 i t OR EPARTMENT USE ONLY �] ( Application Accepted by Date / Area l3 Pit or Grout Inspgp__0.bY ate _ _ _-_ �Einallinspection by _Data) Additional Comments: _ �• -� f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca f823-7104 ❑ Tracy 835-6386--'-) I Applicant - Return all copies to: Environmental Health-Pe rmit/S6rvices 1601 E. Hazelton Ave., P.O'Box 2009, Stk., CA 95201FEE t INFO AMOUNT DUE AMOUNT REMITTED + CASH RECEIVED BY DATE PERMIT NO. ♦ EH13-24(REV.1/n5) r�� EH 14-26 To—Ib (��/'�C1 1