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APPLICATION FOR PERMIT IV SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA 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. Job Address 911, 931, 947, 963, 979, 999 11111 Street CityLathrop Lot Size PM Owner's Name Karen Mayer 370 N. Main , Manteca Phone 739-1374 111411 Vallejo Ct. Contractor Vallejo Const' Inc. Address French Cane, 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 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 1-1 Domestic/Private 171Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1`1 Other ❑ Delta Depth of Grout Seal Type of Grout - %O I I Irritation —Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done v Well Destruction ❑ Well Diameter Sealing Material Stop 501 t�„1 Depth Filler Material (Below 50') tW TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIRIADDITION l I DESTRUCTION I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial_ Other V Y Number of living units: _ I Number of bedrooms Character of soil to a depth of 3 feet: Water table depth W SEPTIC TANK ❑ Type/Mf ment tanks Capacity unknown No. Compartments PKG. TREATMENT PLT. ❑ 1 septic tank Per unit Method of Disposal �D Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. R Length of lines Total length/size �O FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number rpt SUMPS ❑ Distance to nearest: Well Foundation Property Line A DISPOSAL PONDS ❑ e rt 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- 5 tion laws of California." r+1 The applicant must call for all required inspections. Complete drawing on reverse side. / $srzHATox 9/1/87 b � Signed X_ �i� _ Title: Data: FOR DEPARTMENT USE ONLY Application Acceptedby Date � � AM �J 7 Pit or Grout Inspectia Date Final Inspection by Date ` ' ® r�" Additional Comments: k -fi--akt - ❑ Stk 466-6781 ❑ 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 CK 0 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH ' RECEIVED BY DATE PERMIT'NO. + EH13-241REV.i/N5) Eli 1426