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APPLICATION FOR PERMIT _ ' SAN JOAQUIN LOCAL{HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 7 YEAR FROM DATE t 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. i Defense' Depot Trac Chrisman Rd. Trac CA Lot Size Y PM Job Address P Y s City 'i US Army t Office-of Records 4% s" Owner's Name ..Cray . Of Engineers Address r. Phone9 I Contractor - Radian Corp. Address License No. STA Phone9 — Q) TYPE OF WELL/PUMP: NEW WELL ? WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` Q1 See�`EricZ. i FOUNDATIONAGRICULTURE WELL OTHER WELLPITS/SUMPS':_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS see Encl. 2 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing ❑ Domestic/Private ❑ Gravel PackfI' it fg i�Tracy Type of Casings dG' � Specifications �V ❑ Public �i Other Bee Enc ❑ Delta Depth of Grout Seal Type of Grout of ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by 14, 6pP& k97, 9 ❑ Type of Pump �IA H.P. N11ig- State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Materia! (Below 50') �Jj ` TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑. DESTRUCTION ❑ (No septic system parmitted if public sewer is V 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: table depth SEPTIC TANK ❑ T e/Mf 'S ! yp 9 Capacity No. Compartments j PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: W I F ation Property Line LEACHING LINE ❑ No. & Length of line Total length/size FILTER BED ❑ Distance to st: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS—Distance to nearest: Weil Foundation Property Line SAL PONDS 11 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 California."Contractor's hiring or sub-contracting signature certifies the fallowing:"I certify that in the performance of the work for which this permit is issued, I shall employ p y persons subject to workman's compensa- - tion laws of California." � The appGcan st call for al req i ins etions. Complete drawing on reverse side. Signed Title: J&U[0Q1SLData: t F DEPARTMENT USE ONLY Application Accepted by _ Date �`� Area Pit or Grout Inspection by 6- FtD ate fZ—'� �3 Final Inspection by Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104racy` 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Haielton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY. DATE. PERMIT"N0. INFO CASH +EH i -24(REV.7/e5) EH 14-28 • + ,y