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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone {209) 466-8781 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. Job Address 837 B. Thomsen City TAthrop Lot Size 120' X 120' PM Owner's Name Charlie Percival Address S37 E. Thomsen Phone 858-2295 11290 Vallejo Ct. Contractor Vallejo Const. lne, Address French C CA 95231. License No.479838 Phone 982-5661 ..TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [_1 DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing Specifications F] Public n Other ❑ Delta Depth of Grout Seat Type of Grout I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by 5 Repair Work Done 0 Type of Pump H.-R. .State Work Done Well Destruction 0 Well Diameter Sealing Material (top 501 Depth I Filler Material (Below 50') 1 ' TYPE OF SEPTIC WORK: NEW INSTALLATION I7 REPAIR/ADDITION l 1 DESTRUCTION$1 iNo'septic system permitted if public sewer is rn available within 200 feet) Installation will serve: Residence X commercial_ Other t , N3 Number of living units: 1 Number of bedrooms { Character of soil to a depth of 3 feet: I I I Water table depth , SEPTIC TANKS Type/Mfg Cement unknown r Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Viµ. Method of Disposal- ,KJ ►/1 Distance to nearest: Well Foundation Property Line � r i \•v� i r 1 LEACHING LINE LI No. & Lengthlof lines Total length//size FILTER BED ❑ Distance to n'crest: Well Foundation ! t Prop rty,Line• L21 -' YP Cr' SEEPAGE PITS I 1 Depth Size SUMPS ❑ Distance to nearest: Well 1�Fouhdatiofn�} r '- -Property Line DISPOSAL PONDS © '~----�' - A T_ 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. t 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 dr 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 ust call for all required inspections. Complete drawing on reverse side. k f p Signed X ` — --^,,-Title:"'� ,. De[e:` V/ j A6 7 ..s a-_ � _". ��'� F DEPA#iTiNENT USE ONLY Application Accepted by V, Date Area Pit or Gtout Inspection by ; Data Final Inspection by ✓� Date Addition al Comments: c &It 1 0 Stk `466-6781 f Lodi 369-3621 0 Ment a 823-7104 CJ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. + EH 13-24(REV.)/'A 5; < L_� 2 EH 14-26