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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 14101 E. HAZEL T ON AVE., STOCKTON, CA R FE(C E I E D Telephone (209) 466-6781 OCT z 6 1992 j PERMIT EXPIRES 1'YEAR FROM DATE ISSU%V1RQNMENTAL HEALTH ' (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 Healt Di rict.-. .v :� .i + Job Address Sharpe Arty Depot City Lathrop Lot Size Base PM U. S Arm Roth. Rd. L „thro Calif � � Address �' P! Phone209"982-2097 111.Owner's Name ` R.0 . Box 108 contractor Rindahl Drilling Address Corning, Calif . 9609'�,nse No. 601535 Pho1e916-824-01 2 TYPE OF WELL/PUMP: NEW WELLr WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERX❑ Extraction DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE (. FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑,Industrial ❑ Open Bottom fX Manteca Dia. of Well Excavation Dia. of Well Casing 8.11 ❑`,Domestic/Private ) Gravel Pack ❑ Tracy Type of Casing steel 180 wall Specifications _ i`i.>Public (I Other F1 Delta Depth of Grout Seal varies Type of Grout 9-sac E I kIrrigation Va'r'1%prox. Depth I I Eastern Surface Seal Installed by well cap Repair Work Done ❑ Type of Pump H,P. State Work Done _ �T Wellestructon ❑ Well Diameter Sealing Material (top 50') eX�racaL_an Depth, Filler Material (Below 501 rn TYPE OF SEPTIC WORK: NEWINSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is Ji 11available 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: Water table depth � SEPTIC TANK ❑ Typde/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal ; Distance to nearest: Well Foundation Property.Line .I LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin Local Health Di§trict. 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 call for all required inspections. Complete drawing on reverse side. i Signed X Title: Date: 10 '1 (. . 4'2� i FOR DEPARTMENT USE ONLY l Application Accepted by Date f �-- Area 430 _ Pit or Grout Inspection by Date Final Inspection by Date il. VKIA) 3-� v mw �k^ 8 Vow I- Is 6W - S Additional Comments: ❑'.Stk 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 ` l INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT 1V0. +.EH 1324(REV,1/H 51 7{� "� 7(�-.�� g� `— & !P-- q-3Gi�3 EH 14-2k!`8 1 4