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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA t Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED _ (Complete in Triplicate) Application is hereby made to ffie San J4616- 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 14696 Stratford Ave. City Lathrop Lot Size 110' x 396' PM P.D. Box 878 Owner's Name Data Rriyalcaba Address 14696 Stratford Ave. Phone 982-4699 11290 Vallejo Ct. Contractor Vallejo Const., Inc. Address French Camps 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. POOP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM Aki A CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca I Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout r I I Irrigation F..Ap4r`,ox.�Depth l I Eastern � Surface Seal Installed by - � , f & ; Repair Work Done ElType pf Pimp H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 t Depth Filler Material 18elow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR!ADDITION I 1 OESTRUCTIONX i INo septic system permitted if public sewer is available within 200 feet.I CN Installation will serve: Residence Commercial_ Other Number of living units: 1 Number of bedrooms l Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK iType/Mfg Ca=nt i Capacity Rn noWn No. Compartments PKG. TREATMENT PLT. ❑ Y Method of Disposal I XDistance-to-nearest:------Welf—o Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size l FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ['I (Depth Size Number " 1: _ 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 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 shalt not employ any person in such magner_as to becor.pp subject_tp workman.s-compensation.laws.of..Califoroia.,.,_Con.tractor_'s bicing_or sub4ontracting 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 applicanj must call for all required inspections. Complete drawing on reverse side. /7k Signed XTitle: Date: V 00 7 !ARTIMENT USE ONLY Application Accepted-b C - - � eAr;ea�. Pit or Grout Inspection by Date Fina Inspection by 1- r Dat�17L Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy N835:6385'# y NI Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelt6n Ave.,"P:O. Box 2009,Stk„ CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 13-24 IREV.I/R 51 �" L�7 — EH 14-26 . (