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r h APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRIC-q) PAYMENT 1601 E. HAZEL T ON'AVE., STOCKTON CA ` RECEIVE®. Telephone (209) 466-6781 NOV 21 1993 PERMI1" EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQLIIN Cfj;;!.+ry l (Complete in Triplicate) PUBLIC HEALTE4`;1',�' s., rl>✓t$ ENVApplication is hereby made to the San Joaquin L cal Health District for a permit to construct and/or install the work herein described.This apppllicat application made in compliance with San Joaquin County Ord ante No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. I 1 Job Address Defense Depot Tracy Trac _ City _ Y Lot Size 448 acres pM Defense Logistics Agency,DDTC—WB Address Owners Name Mr- Wesley Harris 26500 Chrisman Rd. c + TraY Phone 209 832-9 36 f+ /.as 7949 Ajay Dr. ,Sun Valley Contractor address A, 91352 License No. 561265 Phone_ 81 8 767- 222 TYPE OF WELL/PUMP: NEW WELL tkWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION C11 )Extraction SYSTEM REPAIR ❑ OTHER N2)Injection DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE 3.)�11 pnl tori FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ? INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 3D Gravel Pack Tracy T g�jj[' f"1 Public f] Other Type of Casing Specifications Ll Delta Depth of Grout Seal I i Irrigation ation Type of Grout _.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump Centrifug&43RH P� 1 5 - s � State Work Done, Well Destruction ❑ Well Diameter Va r i an c Sealing Material (top 50') 4 -Depth Filler Material (Below 50') _BenLQn-+ to SI ttrr r _ TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is " , Installation will serve: Residence_ Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity_ Water table depth PKC. TREATMENT PLT. ❑ No. Compartments Method of Disposal Distance to nearest: Well Foundation Property Line ` \V I' r LEACHING LINE ❑ No. & Length of lines Total length/size � FILTER BED ❑ Distance to nearest: Well Foundation Property Line g t� SEEPAGE PITS I I Depth Size Number SUMPS D Distance to nearest: Well Foundation mss. DISPOSAL PONDS ❑ Property Line 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 l 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 California." Contractor's hiring or sub-contracting signature a certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ t tion laws of California." p p y persons subject to workman's compensa- The applicant mus all f 11 re d i ctions. Compl a drawing on reverse side. Signed � + Title: President Date: 11 -6-89 R DE ENT USE ONLY Application Accepted by Date Pit or Grout Inspection by Date_l ^21'/0t2) Final Inspection by D � - ate Additional Comments: ❑ SIk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 P Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GK INFO CASH RECEIVED BYEDE PERMIT'Nt]. +.EH 13.24(REV.1 i H 51 `Ir EH 14.211'