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. ' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT tt tt L 1601 E. HAZE IT ON AVE., STOCKTON, CA L 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, 15871 7th Street Lathrop 75' x 120' Job Address City Lot Size PM Betty L. Shutterly - 7091 Prince Drive (415) 828-5629 Owner's Name. Address Dublin., CA Phone 11290 Vallejo Ct. Contractor Vallejo Const. Inc. Address French Camp, CA 95231 License N0.479838 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 USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial w ❑ Open Bottom T ❑ Manteca Dia. of Well Excavation Dia. of Well Casing - ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing Specifications f 1 Public Cl Other (7 Delta_ Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth, { I'Eastern Surface Seal Installed by _ I Repair Work Done ❑ Type of Pump H.P. - State Work Done — Well Destruction ❑ Well Diameter waling-Material-{top 501 Depth Fj166r,%Material (Below 501 OD TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAtRfADDITION`i 1 [)ESTRUCTIONAX (No septic system permitted if public sewer is °� available within 200 feet.] I Installation will serve: ResidenceX -' Commercia Otherrt Number of living units: 1 Number of.bedrooms. [ _ fY Character of soil to a depth of 3 feet: Water table depth c rt 'SEPTIC TANK 1 ❑ Type/Mfg $edwOOd Capacity Unknown No. Compartments � pt PKG. TREATMENT PLT. Q _ - .,- Method of Disposal t I Distance to nearest: Well Foundation Property Line _ I LEACHING LINE ❑ No. & Length of lines- Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number l SUMPS ] Ll Distance to nearest: Well Foundation Property Line i I 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: "f 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."Contractors 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." I The applicantimust all for all required inspections. Complete drawing on reverse side. Signed X Title: Estimator Date: 9/24/87 DEPARTMENT USE ONLY00�, /%�1 �Q�/y ,Application Accepted-by� -� --DateArea Pit or Grout Inspection by ate Final Inspection by Dat } o oo 9t? Additional Comments: _W r'^ ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8237104 ❑ Tracy 835-6385 t Applicant - Return all copies to: Environmental Health,Permit/"Services 1 1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 [ FEE AMOUNT DUE AMOUNT REMITTED CK 4F CASH RECEIVED BY DATE PERMIT'NO. INFO f + EH 1324(REV.I/A 51 1/'� i t k QU, � oO EH 14-28 / "'�'1