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i APPLICATION FOR PERMIT rrLn SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) I 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. 576 Thomsen City Lathrop Loc size 100' a 100' PM Job Address Pfarlita BBngcayao 576 Thomsen, Lathrop Phone $58-2114 Owner's Name Contractor Vallejo' Cotnst. 'Tac.,...,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 ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'I Public i_l Other F1 Delta Depth of Grout Seat Type of Grout I I i Irrigation --Approx. Depth I I Eastern Surface Seal Installed by _ Repair Work Done LJ Type of Pump H.P. State Work Done— Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 Depth Filler Material !Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION Mo septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence S Commercial— Other : Number of living units: IL Number of bedrooms it Character of soil to a depth of 3 feet: Water table depth v t7� SEPTIC TANK ❑ Type/Mfg Cemnt Capacity Un IItJTM No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal C Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 16 l 1 Depth Size Number SUMPS Cl 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 parsons subject to workman's compensa- tion laws of California." C The applicant ust call all required inspections. Complete drawing on reverse side. Signed X Title: Estimator Date: . 9/2/87 FOR DEPARTMENT USE ONLY Z Application Accepted by Date Area 13 Pit or Grout Inspectio y Date Final Inspection by Date 7 / � Additional Comments: /tZ -. - - -- - ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 LITracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASlt + EH13-24{REV.5 x 57 . . 'S 41 EH 14-2e