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. ' y l3' APPLICATION FOR PERMIT 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED a� a (Complete in Triplicate) nstall the work . This cation is madecation in is hei b/e wimade 0 th San J�uan County Local ncte Nto.549 for sewage or h District for a permitNo. 1862 for cweu pumt and/or p and the Rules and(Regulations of the San s Joaquin Local Health District. 14712 Stratfordcity Lathrop Lot Size 1 acre PM Job Address Barbara Arnold 14712 Stratford Phone 483-1242 Owner's Name Address 129© V lle o t. Lathrop 479838 982-5661 Contractor Vallejo Const. Inc., Address j License No. Phone TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT 171DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �S-E-W�ER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRIC'J TURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBILEMAREAI CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca-''r Dia. of Well Excavation Dia. of Well Casing ❑ DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications F] Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout —.— I } Irrigation _Approx. Depth I l Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 1�1 Depth """' Fitllrr 1Vlatial-CBeloar 50'1 T ] �' TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION i (Nos Attic systthiem emieet tted if public sewer is Installation will serve: Residence— Commercial_ Other Number of living units: _.-I— Number of Sbedrooms -.- Character of soil to a depth of 3 feet: ! Water table depth gg amen nn norm ' SEPTIC TANK Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line � f LEACHING LINE ❑ No. & Length of lines Total length/size ` I # FILTER BED ❑ Distance to nearest: Well Foundation Property Line i t SEEPAGE PITS I Depth Size Number t SUMPS LlDistance to newest:•---Well-7:—Fotmdation Property-t--ine-�-�-"-" DISPOSAL PONDS ❑ { hereby certify that{ 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 I 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 applica must call for all required inspections. Complete drawing on re erse si l. Signed X Title: . Date: R ENT USE ONLY �c � ^� ��^^- pg'te_ - Ya % �_ Area Application Acc pted bye ' Pit or Grout Inspection by to Final Inspection by at Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca-ti 623-7104 '� ❑ET�acy 835-6385 j 1i Applicant Return all copies to: Environmental Health Permit/Sbrvices 1601 E. Hazelton-Ave., P.0-. bxi2009, Stk., CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 11VFQ fes} �] 7 + Eli 13-24(REV.t/x s l [..� � 1 -�-S / k7- EH I - 1 EH 14-26 l i