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` APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 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. Job Address 15415 S. 6th Street City Lathrop Lot Size 125' s 150' PM P.O. Boa 325 Owner's Nam a nneth Mullins Address 15415 S. 6th Street Phone 858-4602 11290 Vallejo Ct. Coni for Vallejo Const. Inc. Address French Camps CA 9523 _ License No.479838 t Phone 982-5661 TYP OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I 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 I ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (`I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1 1 Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by # _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION 4 INo septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence 1 Commercial_ Other Number of living units: 1 Number of bedrooms - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg Cement Capacity unknown r�.Ncr.-COmpartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line k i } L LEACHING LINE ❑ No. & Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: Well Foundation roperty Line SEEPAGE PITS f I Depth Size a .`: Numbs SUMPS D Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ I hereby certify that i have prepared this application and that the work wilt u-dIIrrB'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 th'ii following: "I certify thaun the performance of:the work Tot which this permit is issued, I shall not employ any person in such manner as to become subject to workman's co#rnpensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this peimit is issued,l shall employ prsons subject to workman's compensa- tion laws of California." ,.,, .__._.a I The applicant must call for all required inspections. Complete drawing on reverse side. L__ I R Signed X .GL- Title: FOR DEPARTMENT US-E ONLY iI v 1 4 ; i Application Accepted by L---' t Date r Area Pit or Grout Inspection Date Final Inspection by Date 1 � j Additional Comments:--- _-* -• - - — d-- ""- '"' "" ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7.104% 0ITra�y 83x6385 Applicant - Return all copies to: Environmental Health Permi4Seruii s�1601 E. Hazeton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK A RECEIVED BY DATE PERMIT NO. • EH 14-24{qEV,r i x 51 4-ZB EH