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APPLICATION FOR PERMIT FI SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1��L__��,hp City Lathrop Lot Size �;�^eg2,T— PM Owner's Name AddressE~j Phone 408 268 1772 i Contractor� a -k y (Z I I - Address License No.-3'71 9 Phone TYPE OF WELlL/PUMP: NEW WELL ❑ WELL REPLACEMENT IR DESTRUCTION ` PUMP INSTALLATION a SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL --311-1 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial I� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 10 51a" Dia. of Well Casing 6 5181rl ��omesticlPrivate kq}Gravel Pack ❑ Tracy Type of Casing S#aa1 Specifications #12 F1 Public F1 Other F1 Delta Depth of Grout Seal �Q fl — Type of Grout 9 I I Irrigation —.Approx. Depth E I Eastern Surface Seal Installed by Clark _ '\ Repair Work Done LJ Type of Pump G»�.,-u� H.P. State Work Done _ �P St a-] Q Well Destruction I�C Well Diameter 4 rr Sealing Material (top 501 30 r -9 s k Depth -3n r Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 'I1; available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TAN ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well T Foundation Property Line I +, LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED I ❑ Distance to nearest: Well Foundation Property Line qq SEEPAGE PI T5 I I Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 p y an y person in such nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fdllo wing- certify that r perfotmance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of C' r The applica cal o al req ditio Coptete drawing on reverse side. Signed X I� Title: VP-Clark Well Date: 3 Aug 1989 FOR DEPARTMENT USE ONLY c Application Accepted by Date " �—' Area 7 Pit or Grout IYYspection by Date F Final Inspectio by Date z tJ 11 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- 5 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I- FEE CK 41 t IN O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. s-EH 13-241PEV.FiH5r i 1� �3_ 9 as3 EH 14.211 y V o II