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t k APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 3I; (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.. .. 500 E. Louise Avet Lathrop Lot Size � PM Job Address City L-0--F PO Box 128 Lathrop Phone 858-5151 Owner's Name Address - Clark Well Phone 462--5597 f Contractor's Name License No. one ❑ 1-1WELL REPLACEMENT , DESTRUCTION ❑ TYPE OF WELL/PUMP: NEW WELL ; PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERXK Monitoring l DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES'` DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial 0 Open Bottom 0-Manteca Dia. of Well Excavation Dia, of Well Casing ❑ Domestic/Private ❑ Gravel Pack ElTracy Type of Casing Specifications ❑ Public ❑ Other I1 ❑ Delta Depth of Grout Seal- i Type of Grout r n ❑ Irrigation __4pprox. Depth ❑ Eastern Surface Seal Insta lied by �. 0 F Repair Work Done ❑ Type of Pump H.P. -'_State Work Done Well Destruction ❑ Well Diameter Sealing.Material (top 501 I Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION•❑ (No septic system permitted if public sewer is ` available within 200 feet.) , Installation will serve: Residence Commercial— Other rte' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:) Water table depth SEPTIC TANK ❑ Type/Mfg„ Capacity ` " No. Compartments [' f Method of Disposal (fin PKG. TREATMENT PLT. ❑ r� s 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 i SEEPAGE PITS E3Depth ASize Number SUMPS ❑ Distance to nearest: Well Foundation Property Line l DISPOSAL PONDS ❑ I '1 -� 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 workman's compensation laws of Calrfornr'"Contractors hiring or sub-contracting signature certifies the followin I cert( he performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- g:. tion laws of California." The applicant all al eq ins S. C pi to drawing on re e.. ` `l] Signed Title: Date: ——4f—I =r _ R P SE ONLY c� F l Application Accepted by Date d Area I r / , Pi or Grout Ins to r Date Final Inspection by Date Additional Comments• ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-71W ❑ Tracy 635-6385 Applicant- Return a I copies to: Environmental Health Permit/Services 1601 E. Bpx azelton Ave., P.O. 2009, St.., CA X201 IZ Get i i R& cic FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI 'NO. INFO +' CASH 2 + EH 1324{REV.101531 Eli 14-26 - I