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APPLICATION FOR PERMIT t SAN JOAQUIN LOCAL HEALTH DISTRICT n L n w D 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 15982 Cambridge CityLathrop Lot Size 100' x 100' PM TAthr0 Brethren Church Owner's Name I? ren Address P•0• BO7C 738 Phone 858®2153 11290 Vallejo Ct. ContractorVallejo Const. Idle 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 Dia. of Well Casing O Domestic/Private 1-1Gravel Pack ❑ Tracy Type of Casing Specifications r] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ I 1 Irrigation —.-Approx. Depth t I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 t~jr Depth Filler Material (Below 501 0�y0� k W i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION {.I DESTRUCTION IX INo septic system permitted if public sewer is ha a available within 200 feet.I Installation will serve: Residence X Commercial--r Other Number of living units: l Number of bedrooms Character of soil to a depth of 3 feet: Water table depth , SEPTIC TANK ❑ Type/Mfg Cement Capacity UnknCRM No. Compartments PKG. TREATMENT PLT. ❑' _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ` FILTER BED ❑I. Distance to nearest: Well Foundation Property Lineyr SEEPAGE PITS I I. 'Depth Size Number # O SUMPS 0 Distance to nearest: Well vFoundation Property Line b DISPOSAL PONDS n. 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- tion laws of California." The applicarlt must call for all required inspections. Complete drawing on reverse side. Signed X Title: Estimator Date: 9/9/87 �. .a...F � �Qk �R DEPARTMENT USE ONLY Application Accepted by r` S__V,— - &A6 A-� Date Cl— ^`' Area 13 Pit or Grout Inspection by . I Date Final Inspection by40Date Additional Comments: c ❑ Stk 466-6781 ❑ Lodi 30-3621 ❑ Manteca 623-7104 ❑ Tracy 635-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 n FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVEDBY DATE PERMIT'NO. INFO CASH �j + EH 13-24 MEV.t/N 5) 07 C`J EH 14-28 J l_.U�