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• APPLICATION FOR PERMIT • <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> 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 <br /> Local Health District. <br /> Job Address 500 E. Louise Ave city Lathrop Lot Sae PM <br /> Owner's Name L-0—F Address p0 Box 128 Lathrop Phone 858-5151 <br /> Contractor's Name Clark Well License No. 371560 Phone 462-5597 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERXX Monitoring <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by VI <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done 0 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 6 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal t <br /> Distance to nearest: Well Foundation Property Line VITT' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 <br /> rules and regulations of the San Joaquin Local Health District. ' <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certi �he performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." ^ �� <br /> The applicant s all a) eq ins s. C pl to drawing on�re�rs�a. ^ r <br /> Signed Title: // Date: S V <br /> R EP SE ONLY �7� <br /> Application Accepted by Date "7– 3 a s Area ZT" <br /> Pit or Grout Inspe to y Date Final Inspection by Date <br /> e <br /> Additional Comments: — <br /> ❑ Stk 466-6781 ❑ Lodi Manteca 823-71 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED OK RECEIVED BY DATE PERMIT NO. <br /> INFO 1 CASH <br /> EH 13201REV. 10/931 IRS_31 <br /> EH 1426 <br />