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APPLICATION FOR PERMIT Q SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 1 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 14790 Stratford ave. City LathOrp_ Lot Size PM Owner's Name Harold L.Kenitzer Address 14790 Stratford ave_ Phone 983-0396 Contractor SELF Address License No. Phone 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 W L OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PR LEM AREA NSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Ma eca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications II 71 Public ❑ Other (a Delta Depth of Grout Seal Type of Grout _ 1 I Irrigation _Approx. Depth I I tern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 -- Depth Filler Material IBelow 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION 1 1 DESTRUCTION 1x1 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence--X- Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line [� LEACHING LINE ❑ No. & Length of limes Total length/size v J FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 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 applicant must call for all requireA inspe Complete drawing on reverse side. E Signed X v - Title: Homeowner Date: Aug 1987 F EPARTMENT USE ONLY I Application Accepted by Date Area I i f Pit or Grout 1riWection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 '. Lz El 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 H RECEIVED BY DATE PERMIT'NO. INFO + EH 1324(REV.i/AS) s ��-