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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.-HAZE T ON AVEC, 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 17100 S. Harlan Road City Lathrop Lot Size PM Owner's Name E.R. CARPENTER CO. `Address P.O.- Box 27205, Richmond,VA. Phone Contractor CHAS. H. BLOOM CO. Address P.O. Box 267,Stockton License No. 249055 Phone 948-4121 TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST:'SEP-TX TANK, SEWER LINES DISPOSAL FLD. PROP, LINE F66NDATIONAGRICULTURE WELL OTHER WELL - PITS/SUMPS INTENDEDIUSE TY-PE-OF"WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial " ❑ipperi,Bottom ❑ Manteca Dia. of Well Excavation �fDia. of Well Casing ❑ Domestic/Private ❑"Gravel.Pack ❑ Tracy Type of Casing y Specifications Fl Public Other `. ❑ Qelta Depth of Grout Seal r., Type of Grout I I Irrigation , g-ppprox'PDepth I ! Eastern Surface Seal Installed by Repair Work Done 0'k%Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material ltop 501 O Depth Filler Material (Below 50') -- TYPE OF SEPTIC WORK: NEW INSTALLATION 14 REPAIR/ADDITION 1.1 DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Commercial X Other Number of living units: Number of bedrooms ,� 1 Character of soil to a depth of 3 feet: P & L Concrete Products Water table depth SEPTIC TANK © Type/Mfg 1 Capacity 3,000 No. Compartments N:PKG. TREATMENT P , _ � Method of Disposal Distance to nearest: Well Foundation~ Property Line. LEACHING LINE No: &Length of lines �� Total length/size FILTER BED f❑ Distance to nearest: Well ,4 dation Property Line i SEEPAGE PITS.., l I Depth 3 Size S � ` _ Number SUMPS' {F Ll Distance to nearest: Well Fouridation.r. Property Line DISPOSAL PONDS ❑ ` I herehy certify iliai I have prepared this application and that the work will be,done in accordance with San Joaquin county ordinances, state laws, and it 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 compen`satiori laws of California." Contractor's hiring or sub-contracting signature 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- tion laws of California." " The applicant mprtllil for aqui inspections. Complete drawing on reverse side. Signed x Title: mer`" Date: 3/14/89 r 1 I' FOR DEPARTMENT USE ONLY 1 Application Accepted by Date r Pit or Grout Inspection Date Finai Inspection by Date r e Additional Comments: ❑ Stk r 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'NO. n +-EH 13-241REV.+/H5) 11 q _.5ra7 EH 14-26 �© s .D /5 S,