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f - APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED IComplete 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 15901 S. 6th Street Cit Lathrop Lot Size 150' x 150' PM P.O. Box A6 Owner's Name John Simons Address 15901 S. 6th Street Phone 858-2130 11290 Vallejo Ct. k ContractorVallejo Const. Inc. 'Address Fre eh Campy CA\ 9 2 License No.479838 Phone 982-5661 TYPE OFWELL-/-PUMP:——NEW-WEL-L—❑— --='WELL R LACE ENT-fes-DESTRt1CT10N-tfl--"-""i +!RU ' P INSTALLATION ❑ SYSTEM REPAIR ❑ N 01HER F)DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL RLD _ PROP. LINE i—FO NDATION AGRICULTURE WELL OTHER WELLL�i j PITSISUMPS I ,,JN,TENZXED44S --- OF WALL_ __P80 LEM EA CONSTRUCTION SPECIFICATIONS + © Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing ❑1D`bmestic/Private 1:1 Gravel Pack ❑ Tracy ype of Casing 1 Specifications f l Public ❑ Other ❑ Delta Dlpth of Grout Seal Type of Grodt _ (115 1-1 Irri tion —Approx. Depth I I Eastern S rface Seal installed by fl — p r" Repair Work Done {7: Type of Pump H.P_,. State Work Done rs'�`•i'��i 1St?'.:yi . 11Vell Destruction C]' WeIE,Lliameier_ _ ____--,F 5eari lg�Mat r�l�Itop 50'I IL Depth Filler Materi i (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR)ADDIT .N_1..L DESTRUCTION*1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other ,. Number of living units: ._._6_... Number of bedrooms €I Character of soil to a.-depth of"3'f"iee . 'I i Water t ble depth SEPTIC TANK A T elMf Cement Ca acit No. Corn artments YP 9 � � Capacity— P lir PKG. TREATMENT . ❑ Methodlof Disposal { Distance to nearest: Weil Foundation Property Line LEACHING LINE ❑ No. & LengthI of lines -To1aI4engthfsize--_1-µ FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS Li Distance to nearest: Well Foundation Property Line C. DISPOSAL PONDS ❑ T) I hereby certify that I Piave prepared this apl5lication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and G rules and regulations of the San Joaquin Local Health District. Home owner or licenseld agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: i'1-certify-that-in-tha-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 applicant ust call for all required inspections. Complete drawing on reverse side. I Signed X Title: Date: + ILI O -DEPARTMENT-USE-ONLY �y a f,� � Application Accepted by v Datey 1 er � Ar�eae Pit or Grout Inspection by Date Final Inspection by�./�i �.! / - Date -7 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 DATE PERMIT'NO. INFO CASH i EH 13-24 1REV.i i m5) ��1 / / G �fa EH 14-28J < `O