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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT rr L " 1601 E. HAZE k ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE_ ISSUED (Complete in Triplicate) Application is.heieby 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 1199 rr U rr Street City Lathrop Lot Size PM Owner's Name Jacob Friesen Address 1199 rr 0 ri St., Lathrop Phone 982-0 0A 1.1290 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 FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing s ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation --`74pprox. Depth I i Eastern Surface Seal installed by _ Repaair Work Done ❑ Type'of Pump H.P. State Work Done _ t Well Destruction ❑ Well Diameter Sealing Material (top 50') I Depth Filler Material (Below 50') 'fl TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION LI DESTRUCTION X (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_X Commercial— Other Number of living units: 1 Number of bedrooms Character of soil to a depth of 3 feet: Water table depth rt SEPTIC TANK ❑ Type/Mfg t.ealent Capacity unknown No. Compartments ) PKG. TREATMENT PLT. ❑ Method of Disposal rt 1 Distance to nearest: Well Foundation Property Line l � 1 r f, + LEACHING LINE ❑ N6. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line + SEEPAGE PITS I I Depth Size Number SUMPS ❑ Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed x Title: Estimator Date: _9/11/87 FOR DEPARTMENT USE ONLY Application Accepted by Date Area 13 V4 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments-72d_ ❑ 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.D. Box 2009, Stk., CA 95201 FEE I INFO AMOUNT DUE AMDUNT REMITTED CASH RECEIVED BY/ DATE PERMIT NO. + EH 13-24(REV.I/H sl 'k EH 14-29 i<