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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE,T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED u (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her described. This application is made H 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 Corner of Park & Fifth Lathrop p Lot Size 100 X 125 25 PM Lathrop County Uater District 15x751 S. 7th �a C'as e-r Owner's Name Address _ � J 8*58-421�i Phone Contractor's Name C l a r k Ue I Z License No. 371560 TYPE OF WELL/PUMP: NEW WELL Phone 462-7676 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ SEWER LINES � DISPOSAL FLO._,_1 0 1 PROP. LINE 251 FOUNDATION AGRICULTURE WELL OTHER WELL 1 SQ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation tt Dia. of Well Casing tt ❑ Domestic/Private XGd Gravel Pack ❑ Tracy Dept of Casing Specifications .2 5 8 ❑ Delta Depth of Grout Seal � S ❑ irrigation ---Approx. Depth ED Eastern Type of Grout ^ Repair Work Done ❑ Type of Pump Surface Seal Installed by "[r H.P, Slate Work Done Well Destruction ❑ Well Diameter Sealing Material (top 54') Depth Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is Installation will serve: ResidenceCommercial_ Other available within 200 feet.) y Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments Distance to nearest: Well Foundation Method of Disposal Property Line LEACHING LINE ❑ No. & Length of lines FILTER BEDTotal length/size ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size SUMPS Number ❑ Distance to nearest: Well Foundation DISPOSAL PONDS F7 Foundation Line 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."Contractors hiring or sub-contracting signature certifies the following: "i certify that in r ce the work for 'ch this permit is issued,I shall employ tion laws of Caorn'a." p p y persons subject to workman's compensa- The applicant s call f .al re uir s ons. o to dr Ing o reverse side. Signed Title: Date: —Clark Uell 15 Jan 1986 F R DEPARTMENT USE ONLY Application Accepted by Date�, �yp Area 441:or Grout inspection by ateM final Inspection by Date Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 anteca 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 FEE AMOUNT DUE AMOUNT REMITTED CK INFO � CASH RECEIVED BY DATE PERMIT"N0. + EH 13-24(REV.10/83) y '/0 tr p EH 1428 �- �L-:rSb �39