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APPLICATION FOR PERMIT SANT JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) PERMIT N0. 'T)Ji-1311 DATE ISSUED 10-10 -TH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein AMOUNT DUE described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump PERMIT NO, and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1¢550 s. Harlan Subdivision Name Lathrop Sands Trailer Park Owner's Name Barbara Stenson Address P.D. Box 301 Rheem Val1Py CR___ Phone 415/376-1373 Contractor's Name Valley Mechanical., In&icense No. 333319 Phone 931-403L TYPE OF WELL/PUMP WORK: NEW WELL E] WELL REPLACEMENT F7 DESTRUCTION PUMP INSTALLATION .E] SYSTEM REPAIR OTHER U DISTANCE TO -NEAREST: SEPTIC TANK "ISEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial U Open Bottom 71 Manteca Dia. of Well Excavation Domestic/Private ❑ Gravel Pack Tracy Dia. of Well Casing Public._ Other Delta Type of Casing Li Irrigation Approx. �J Eastern .- Specifications � (A� ❑ Cathodic Protection Depth ;Depth of -Grout Seal_ i Geophysical - x- ..T w'.... Type of Grout - U Other Surface Seal Installed by Repair Work Done D Type of,Pump H. P. State Work Done Well Oestruction:U Well Diameter _ _ Sealing Material (top 50') Depth a Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION Ci REPAIR/,ADDITION (No,septic tan k'or•seepage pit.permitted<if^public, sewer is available, within 200 feet.) installation will serve:' Residence Commercial XX- Other— therNumber Numberof living units: _ Number of bedrooms Lot size A Character of soil to a depth of 3 feet:- Water table depth SEPTIC TANK )EXj Type/Mfg P & L Conc. Prod. Capacity 1200 No. Compartments PKG. TREATMENT PLT. Type/Mfg Capacity Method of Disposal SEWAGE SYSTEM Distance to nearest: Well Foundation Property Line " v ; DESTRUCTION LEACHING LINE U No. & Length of lines.._ - Total length/size FILTER 8ED LX Distance to nearest: We11 inn Foundation . ooProperty Line 30 SEEPAGE PITS ❑ Depth =Size Number SUMPS Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS C� _ f i 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 workmant compensation laws of California." Contractor's hiring or sub -co tracting signature certifies the following: "I certify that in the performance of the work for which this permit is ued, I sha .femploy persons subject to workman's compensation laws of California." The applic m call r all uir d inspections. Amplete'drawing on reverse side. Signed X (, Ti -0e: Estimator Date: 10-08-84 Application Accepted OR DEPARTMENT USE ONLY _ Area [] Stk 466-6781 Additional Comments: Lodi 369-3621 Pit or Grout Inspection Date �L Lj Manteca 823-7104 Final Inspection by Date- S "4 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, INFO Ed 13-24 REV. 10/82 V 10/82 500 14-26