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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT M I 1601 E. HAZELTON AVE., STOCKTON, CA 00 991 Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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. I Job Address 1202 ThOMea City Lathrop Lot Size PM Owner's Name Church of Christ Address 1202 Thomsen Phone 858-2295 I i 11290 Vallejo Ct. Contractor Vallejo Const. Itis. Address French Camp,, CA 95231 License No.479838 Phone 982-5561 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 I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f 1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1"1 Public n Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ N Well Destruction ❑ Well Diameter Sealing Material (top 50') �` Depth Filler Material (Below 501 }�+ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION$I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Church S Number of living units: Number of bedrooms d Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ?S Type/Mfg Cement Capacity Unknown( No. Compartments 2 PKG. TREATMENT PLT. ❑ Method of Disposal T Distance to nearest: Well Foundation Property Line 5 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line t 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 -5 rules and regulations of the San Joaquin Local Health District. D 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. G �7 Signed X V r � 0 Title: � ^ `' r t Date: o z� r FOp{�`DEPARTMENT USE ONLY Q Application Accepted by Date v-�0Area 13 Pit or Grout Inspection by Date Final Inspection by 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE VPERMIT'NO. INFO CASH ♦ EH13-24ME EH 14-26