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/U° ,et4*1,.V APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT n L n 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES T 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. Jab Address 15424 5th Street City Lathrop Lot Size 100' x 140' PM e. Guzouin Owner's Name 15424 5th Street, Lathrop Phone 982-4310 Vallejo Ct. Contractor Vallejo 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 WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _>r� �0ia"of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i_ _s.pecifiltions ❑ Public n Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by T _ Repair Work Done ❑ Type of Pump H.P. I State Work Done i + Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE: OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I 1 DESTRUCTION IJ INo septic system permitted if public sewer is N available within 200 feet.) Installation will serve: Re Hence�_ Commercial_ Other S Vr 1 rr Number of living units: Number of bedrooms i tr Character of soil to a depth of 3 feet: Water table depth Gam R SEPTIC TANK ❑ Type/Mfg ut Capacity No. Compartments n PKG. TREATMENT PLT_[IY__ Method of Disposal t 0 rr 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 l I Depth Size Number 'd SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C1 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-agents-signature-cenfies`the-following:"I certify�Tftat7n'theT7ertormande of-the wdrk 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: 'q 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 applica must cat] for all required inspections. Complete drawing on reverse side. Signed X Title: _-E--timatQr -_ Date: 9/24/87 OR DEPARTMENT USE ONLY Application Accepted by Date ^� Area 13 Pit or„Grout Inspection"b©- � ``�,.Data "'"^-Final Inspection by — Date /9 ~Additional Comments:/ ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ,.—❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelt6n AVe.,.P.O. Box 2009, Stk., CA 95201 .�311FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. + EH 13-24(FIEV,t i n s) � EH 11-28 _1