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APPLICATION FOR PERMIT L SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 12091 466-6781 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 15985 7th Street City Lathrop Lot Size PM Owner's Name Jim SA der Address 15985 7th Street Phone 858-4415 11290 Vallejo Ct. Contractor Vallejo Const. Inc. Address French Camp, CA 95231 License No. 479838 Phone982-5661 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR LI 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L -❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F-1 Public ❑ Other n Delta Depth of Grout Seat Type of Grout 13 Irrigation --Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done _ a Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material {Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1.1 DESTRUCTIONXI (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - l Water table depth SEPTIC TANK r5 Type/Mfg Cement Capacity Unknown No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 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 I Depth Size Number SUMPS ❑ 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 O 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring osubcontracting suontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to wdrkman's compensa- tion laws of California." if ^r The applicant1 ust call for all required inspections. Complete drawing on reverse side. (�} Date: I 7 Signed Title: 'a { _ FO PAR ENT USE ONLY � i• Application Accepted by Date Area Pit or Grout Inspection by w Date Final.Inspection by Date r Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMODUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. + EH 13.24{REV.r i e 5) EH 14-26 LJCJ L/s J19 Al2 .Q ,3