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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZETON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 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. 'e�0 � �1 fes'� 20 �©-0� J !t�$'_ Job Address Sharpe Army Depot city Lathrop Lot Size 800 AC PM Owner's Name U.S . Army Address Rath Rd Lathrop , Oa. Phone 209-982-2097 P.O . Box 108 Contractor North Valley Lrij4Ngs Corning, Ga. 96021 License No. 418834 Phone 916-824.-03 62 TYPE OF WELL/PUMP: NEW WELL I';Z WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER:�t7 Extraction 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 ❑ Industrial El Open Bottom AJ Manteca Dia. of Well Excavation Dia. of Well Casing g 5 Z 8 ❑ Domestic/Private gGravel Pack ❑ Tracy Type of Casing Steel Specifications I'] Public ❑ Other ❑ Delta Depth of Grout Seal 100, Type of Grout..-Sack S1U I Irrigation 135Approx. Depth I I EasternSurface Seal Installed by Cement Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter 811 Sealing Material (top 501 sack slury Extraction Depth 135 t Filler Material (Below 50') 8 mesh Sand TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is 4 available within 200 feet.I 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 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 L7 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS EI 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 Di1trict. 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 applica ust call for all required inspecti . Complete drawing o v rse side. Signed Title: �Y►,G Date: — 6 F A T USE ONLY Z Application Accepted by Date r3 ~ 3 V Area G C/ Pit or Grout Inspection Date Final Inspection b data 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 FEE INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. + EH 13.26 IREV.I/A 5) 0 �� EH 11-28