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x , <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> 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 <br /> Local Health District. esS £ d­0"]—X( .B�-/✓n <br /> Job Address Sharpe Army. Depot / city 1athrox3 Lot Size 800 aC. PM <br /> Owner's Name U.S . Ar111 Address Roth Rd . Lathrop Phone 209-982-20q71 <br /> F.O. Box 108 <br /> Contractor Korth Valley DrilAAr7pg 0ornin:� Calif .96021-icense No. 418834 Phone-.916-324-0 62 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER Z Soil sampling <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom 1S1 Manteca Dia. of Well Excavation 2 tt Dia. of Well Casing non <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing none Specifications �q <br /> 1-1 Public TO Other f 1 Delta Depth of Grout Seal J-5 1 Type of Grout fat CeMpn <br /> I I Irrigation _.,Approx. Depth I 1 Eastern Surface Seal Installed by Lf <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 Neat Ce1-rlE?f}.t <br /> Soil samplinZ Depth 15 T _____ __ Filler Material (Below 501 <br /> f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence_ Commercial— Other ; <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments rr � <br /> PKG. TREATMENT PLT. ❑ Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS { I Depth Size Number <br /> SUMPS LJ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> 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, an <br /> rules and regulations of the San Joaquin Local Health Ds§trict. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applica must call for all required ins ctions. Complete drawing on reverse side. (� <br /> Signed X Title: Date: _ /6 — S 6 <br /> FO T USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection b r <br /> Y Date Final Inspection b Date T7�T U <br /> Additional Comments: <br /> f❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE)NFO AMOUNT DUE AMOUNT REMITTED ��CASH RECEIVED BY DATE PERMi7'NO. <br /> + EH 1324 iREV.t i n 51 �r/ t' �� <br /> EH 14-2a W I <br />