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F APPLICATION FOR PERMIT tV171+3 � SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 rr L tr 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 Nb. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 267 & 275 Shilling Ave. City Lathr92 Lot Size 100' x 228' PM 1 1366 Wimbledon Owners Name Violet Go€stein Address Manteca, CA 95336 Phone 239- 10 11290 Vallejo Ct. Contractor Vallejo Const. Ift 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 FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL_ ___ OTHER}/yF_j j_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ i Dia- of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications .. i f-7 Public n Other Cl Delta Depth of Grout Seal 1t Type of Grout I I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by— ' y Repair Work Done ❑ Type of Pump H.P. State �tork Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 4=3 i-" C TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I I DESTRU TION RG 'f, ,Nq seBptic system permitted�if^pi bfic sewer is W i by a le within(ZDO feet.) Installation will serve: Residence X Commercial Other € -` Number of living units: 2 . Number of bedrooms Character of soil to a depth of 3 feet!: 1 1 Water table depth C SEPTIC TANK X*] Type/Mfg Cement Capacity unkaot n No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance-to nearest: Well Foundation; r Property Line i I S Y LEACHING LINE -x --- - -CI—No-&-L-ength-of-litres Total length/size FILTER BED 0 Distance to nearest: Well IFoundatio i Property Line i SEEPAGE PITS I I Depth Size Numbter SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONIIS 114 a 4 L = I hereby certify that I have prepared this application and that the work will be done I,n accordanca with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. IN Home owner or licensed agent's signature certifies the following: "I certif l 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 compensatiorp,laws of California."Contractor's hiring or sub-contracting signature 1 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 must coq for all required inspections. Complete drawing on reverse side. - -Tia,Signed X Trtle, `8atimator 101587. - Date: I I IOR EPARTMENT USE ONLY Application Accepted by dA,, +. -n, .r.nCA8 Date O r Area 13 Pit or Gra_ut Inspection by _Date- - -Enal lnspection_by - . -_Dater Additional Comments: ❑ Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca 1823-7104 ❑ Tracy 835-6386 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. + EH1 -24iREV.tiK5€ EH 144-28 O