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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA S3 Telephone 1209) 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 clZAIL. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rutes and Regulations of the San Joaquin Local Health District. M w7 -Job Address Defense Depot Tracy, Chrisman Rd. city Tracy, CA. Lot Size 448 Acres .PM U.S. Army Office of Records Owner's Name Corp_'of Engineers Address 650 Cap it-a1 Ma11 , Sar- Phone 916-44Q-2407 United States. Enviro. �h Contractor's Name Hygiene Agency License No. N.A. Phone TYPE OF WELL/PUMP: -x ',,-,,, NEW WELL,E) WELL REPLACEMENT 11 � DESTRUCTION ❑ t •_. WELL � PUMP-.1NSTALLATION ❑ SYSTEM REPAIR ❑,, OTHER ❑ DISTANCE TO NEAREST: 'SEPTIC TANK�' "� SEWER'LINES�`` 4Y- s DISPOSAL' FLO."� PROP. LINE See Fnrl #1 FOUNDATION AGRICULTURE WELL _ OTHER WELL.. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS See Encl. #2 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack r Tracy Type of Casing Specifications ❑ Public Q(Other See En�1❑ Delta Depth of Grout Seal Type of Grout Irfig�a cLn ---Approx. Depth L❑ Eastern Surface Seal Installed by N epaiiir or one g❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 601 Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sew available within 200 feet.) L Installation will serve: Residence— Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: er table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: Well ation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to st: Well Foundation Property Line SEEPAGE PITS Depth Size Number Q SUMPS ❑ Distance to nearest: Well Foundation Property Line 1 D AL PONDS ❑ 1 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 t 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 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 must calf I required ' sp s. Complete drawing r s e. T,I Drrecttor 0 Lnse nT Exvices Signed Title: Date: y M�I FOR DEPARTMENT USE ONLY f� Application Accepted by • 1 f , Date �3� � Area Pit or Grout Inspection by Li�%s'lfl«'�— Data S �� Final Inspection by1117 Additional C ants: L $tk 6781 ❑ Lodi 3821 ❑ Manteca 823-7104 Trac 835-6385 Applicant- eturn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 v FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. INFO CASH + EH 241REV.10!$3}W EH 1426 i r