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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA n L 1t Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) w 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 ) I Job Address 15801 �ialtl►ar Lahe CityLathrop _ Lot Size 100 t x 00 t PM_ P.O. Box 94 Owner's Name Generuso Baghon Address 15801 8almar LD., Lecthrop Phone _982-1752 —11290 Vallejo Ct. I. ConlractorVallejo Const, Iris; Address French Cagp, CA 95231 License No.479838 Phone 282-566 TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT 11 DESTRUCTION EJ PUMP INSTALLATION ❑ SYSTEM REPAIR EI 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 ❑ Gravel Pack ❑ Tracy Type of Casigg- Specifications I f-I Public F Other Cl Delta Depth of Grout Seal Type of Grout i i i I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed Repair Work Done- ❑ Type of Pump H.P. State Work Dole_ Well Destruction ❑ Well Diameter Sealing Material (top 50') i Depth Filler Material {Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION i.l DESTRUCTIO,__ . jNo septic system peer�mitted if public sewer is available within 200 feet.) w Installation will serve: Residence�� Commercial_ Other � Number of living units: 1 Number of bedrooms _ 0© r Character of soil to a depth of 3 feet: - � Water table depth SEPTIC TANK ` 1 "p ' T e/Mf Cemut k E YP g Capacity No, Compartments 2 PKG. TREATMENT PUT. ❑ W it Method of Disposal � Distance to nearest: Well Foundation Property Line LEACHING LINE * ❑ No: & Length of lines Total length/size FILTER BED ❑ Distance to:nearest: ' Well Foundation Property Line SEEPAGE PITS qq I i Depth Size Number SUMPS p L-1 Distance to nearest: Well Foundation _ Prop_erty Line _ f DISPOSAL PONDS ❑ O 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. Homeowner 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 shaft employ persons subject to workman's compensa- tion laws of California." The applica r1t must call for all required inspections. Complete drawing on reverse side. Signed X Title: Estimator Date: 924/87 aEPARTMENT USE ONLY ��._ Application Accepted byDate •� 7 Area 13 t Pit or Grout Inspection by /90/ yDatey _i Final Inspection by Date/p Additional Commeo arJ ,fc—J 7-f " ❑ Stk 466-6781 y ❑ 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. x + EH 13-24(REV.1/0 51