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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA L Telephone (209) 466-6781 ' 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. j Job Address 1150 Thomsen City Lathrop Lot Size PM owner's Name Martha Cabreros Address 726 Maxwell Lane Lathro Phone 858-4335 ContractorWlejo Const. Inc Address 112901,VillieJo Pt a License No.479838 Phone 982-5661 MW 5211TYPE 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 WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial , ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private F] Gravel Pack L1Tracy Type of Casing Specifications I' Public ❑ Other FI Delta Depth of Grout Seal Type of Grout I Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') OL Depth Filler Material (Below 501 1 TYPE OF SEPTIC WORK: . NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTIONXX INo septic system permitted if public sewer is 0 available within 200 feet.) D Installation will serve: Residence 8 Commercial_ Other Number of living units: 1 Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg {relent Capacity!Inknoya No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f3' LEACHING LINE ❑ No. & Length of lines Total length/size K C FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 fnust call for all required inspections. Complete drawing on reverse side. Signed X Title: Estilmator Date: 8/25/87 FOR DEPARTMENT USE ONLY Application Accepted by Date ! Area Pit or Grout Inspection O Q_ r Date Final Inspection by40� Date Additional Comments: X, T�1.1.a .psi 4. _— ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201y� FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. Q INFO EH 1 -24IREV.I/A5l EH 144-28 Atl �JY3