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t i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE.,'STOCKTON, CA Telephone (209) 466-6781 rf L rr PERMIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) I 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 365 .8. Louise Avenue' ' City Lathrop Lot Size rr PM �I ,-Owner's Name Frank Ryan Address219 Distel Ave., Los Altos Phone(415) 948-0430 a 11290 Vallejo Ct. Contractorvallejo Const. Inc" Address French Camp, 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 FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELt 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 Casing Specifications ['I Public Cl Other Cl Delta Depth of Grout Seal Type of Grout _ I f Irrigation Approx. Depth l J Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump; H.P.- State Work Done f Well Destruction ❑ Well Diameter] Sealing Material (top 501 :l Depth { Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I, REPAIR/ADDITION ( I DESTRUCTION € (No septic system permitted if public sewer is available within 200 feet.) Installation'will senie_:-Residence " Commercial_ Other Mobilehome. Park. e Number of living units: Number of bedrooms s C Character of soil to a depth of 3 feet: Water table depth to SEPTIC TANK 1 Type/Mfg llCement .2 Capacity Unknown No. Compartments n PKG. TREATMENT PLT. ❑ -,. zr _ .� Method of Disposal 4 Distance to nearest: Well Foundation: Property Line F+ LEACHING LINE ❑ No. & Length of lines Total length/size C FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 ro SEEPAGE PITS 1.1 Depth t Size Number $0 SUMPS ` ri _ ❑ Distance to nearest: WeII Foundation Property Line 1R' DISPOSAL PONDS- 71 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 r 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 corimpensa- tion laws of California." ! The applica ' ust call for all•required inspections. Complete drawing on reverse side. Signed X .Title: Estimator / Date: 9/16/87 FOR DEPARTMENT USE ONLY Application Accepted'by OL Date L q—tT Area 13 I �' r Pit or Grout Inspection by Date Final Inspection by r'' Datt_ k Additional Comments:NAD ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 . 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 CK 4 ASH RECEIVED BY + DATE PERMIT'NO. i + EH 13-24(REV.1/k51 3�U ' EH 144-28 �-