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.. APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 RECEIVED (209) 468-3 _-)4,-tCL) r'DQ 0 1 1991 R PROM DATE ISSUED SAN,JOAQUI N CG.:%J T Y (Complete in Triplicate) PUBLIC HEALTH Si-:I"';� SES ENVIRONMENTAL HEALfr=L;IVISION Application is hereby made,to San Joaquin County 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 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. t f Job Address - U' � � City Zathrop Lot Size/Acreage Base Owner's Name Sharpe Army Depot -Add re ©L -- ss Lathrop , Calif. Phone 209- Cont►actor Rindahl 1)rillin9 Address Corning, Calif. 9602 ease N0601535 Phone 916-824-"0 62 TYPE OF WELL/PUMP: NEW WELL a WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial © Open Bottom Manteca Dia. of Well Excavation I0 Dia. of Well Casing 411 U Domestic/Private -1 Gravel Pack ❑ Tracy Type of Casing PVC Specifications * Public til Other ❑ Delta Depth of Grow Seal Varies Type of GroutNeat cemen 0 fmoauon Vari4Wrox. Depth ❑ Eastern Surface Seal Installed by Well ca-D _ -_� 0 Repair Work Done U Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIAODITION 0 DESTRUCTION G (No septic system permitted if public sewer is 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: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. G) Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 rules and regulations of the San Joaquin County 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-convecting 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 in ctions. Complete drawing on reverse side, Signed X 12A Title: Owner Date: I FOR DEPARTMENT USE ONLY q Application Accepted by r+�"/ q Date f Area Pit or Grout Inspection by Date �< Final Inspection by Date Additional Comments: Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT AEMtTTED �K RE EIVED BY DATE PERMIT NO. INFO CASH