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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT rt rr 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 15545 6th Street CityLathrop Lot Size 125' x 154' PM P.O. Box 926 Owner's Name Judy rs Address 15545 6th St., Lathrop, CAPhone 858-2032 11290 Vallejo Ct. Contractor Vallejo Const, Inc. Address French Catnap, 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 WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ lndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'l Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout _ I I 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 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f I DESTRUCTIONXII (No septic system permitted if public sewer is available within 200 feet.) w Installation will serve: Residence $ Commercial_ Other Ln to Number of living units: Number of bedrooms 4p, N1 Character of soil to a depth of 3 feet: Water table depth 0% SEPTIC TANK 14 Type/Mfg Cement Capacity unknown No. Compartments a PKG. TREATMENT PLT. ❑ Method of Disposal to Distance to nearest: Well FoundationProperty tine M LEACHING LINE ❑ No. & Length of linesrt Tota! length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Numbery SUMPS Cl Distance to nearest: Well FoundationProperty Line 0 DISPOSAL PONDS 171 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: "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: "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." The applican must call for all required inspections. Complete drawing on reverse side. Signed x Title: Estimator 9/16/87 Date: FOR DEPARTMENT USE ONLY Application Accepted by U—AG1 Date Area 13 Pit or Grout Inspection by .^ Date Final Inspection by bate Additional Comments: ❑ Stk 466-6781 ❑ Lodi 3694621 ❑ Manteca 823-7104 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PE111,1IT'N0. + EH 13-24 04 EV.r/x 51 C.2 0 EH 1428