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r. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> 911, 931, 947, 963, 979, 999 "11" Street Lathrop <br /> Jab Address City Lot Size PM <br /> Owner's Name Karen Meyer s 370 P. Main , Manteca Phone 239-1374 <br /> 11O Vallejo Ct, <br /> Contractor Vallejo Const, Inc. Address French Camp, CA 95231 License No.479838 Phone 982-5661 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED 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 /> n Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout %D <br /> I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by !-+ <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> La <br /> Depth Filler Material (Below 501 w <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION l 1 DESTRUCTION I (No septic system permitted if public sewer is <br /> available within 200 feet.) y. <br /> Installation will serve: Residence- Commercial— Other <br /> Y <br /> Number of living units: 1 Number of bedrooms <br /> Character of soil to a depth of 3 feet: Q' <br /> p Water table depth V,y <br /> SEPTIC TANK ❑ T Cement tanks un noun <br /> Type/Mf Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ 1 siptlC tan per ufn t Method of Disposal v <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines <br /> 9 Total length/size �p <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number to <br /> SUMPS ❑ Distance to nearest: Well FoundationPro rr <br /> Property Line n <br /> DISPOSAL PONDS ❑ 0 <br /> 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 <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." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." 5.H <br /> The applicant pust call for all required inspections. Complete drawing on reverse side. 0i <br /> I <br /> Signed Title: $STD(ATOR Date: 9/1/87 Py <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by gal& Date AM <br /> Pit or Grout lnspecti bate Final Inspection by Date ` © _Y7 <br /> Additional Comments: x ~ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 523-7104 -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 /> IrFEEO AMOUNT DUE AMOUNT REMITTED CASH / RECEIVED BY DATE PERMIT'NO. <br /> + EH13.2AfREV.I/k51 <br /> EH <br />