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r APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT n L sr ' 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 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 46VL5=ZtR9xfte•. 14601 Stratford City Lathrop Lot Size 150' x 450' PM Owner's Name Denny Keeler Address 14601 Stratford, Lathrop Phone 83-071 11240 VA-Rejo-Ct.. Contractor Vallejo Const. '6C Address French Camp, 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 i r 6 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ ?_ T INTENDED USETYPE OF WELL PROBL•EM'AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing W ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f l Public Cl Other ! C-1 Delta Depth of Grout Seal Type of Grout -- 1 1 Irrigation _ A ? 0 g' pprox: Depth I 1 Eastern Surface Seal Installed by - _ � Repair Work Done ❑ Type of Pump H.P. State Work Done ¢' Well Destruction EDWell Diameter Sealing Material (top 501 E f iDepth j Filler Material (Below 501 R TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION-i-i--DESTRl3C�lON-tX-{No-septic-system permitted if public sewer is 1 available within 200 feet.I tnstallation will serve: Residence X Commercial-_- Other! � Number of living units: _I_ . Number of bedrooms t Character of sail to a depth of 3 feet:5 f Water table depth i Cement i ro SEPTIC TANK 1 Type/Mfg _ Capacity unknown No. Compartments PKG. TREATMENT PLT. ❑ 4 Method of Disposal Distance to nearest: Well Foundation Property Line I J LEACHING LINE ❑ No. & Lekgth of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' r 4 { - 1 SEEPAGE PITS 1 I Depth Size Number } 4 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 Joalquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i Home owner or licensed agent's signature certifies the following: "I 4ertify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as ta.become subject to workman s compensation laws of California." ontractor 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 compens4 tion;laws of alifornia." Theftapplic m t c 11 for all required inspections, Complete drawing on reverse side. Signed t Title: Ret-imato- Date: 1QTL5 _— r i FQR DEPARTMENT USE ONLY t Application Accepted by Date �� Area 13 i Pit or Grout inspection by Y Date i Final lnspectiori 6y Dates �� Additional Comments: t %`� ft, ❑ Stk 466-6781 LI 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I a EH 13-24IAEV.I/85) EH 1 4-28 v Vv