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i t APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT . 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 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 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.5 O ,(} '� (2&,n, i h e rm Depot cit Lot size -Ba5e __- PM Jab Address Y��— � Owner's Name U.• C . Army Address 250 Lathrop Rd• Phone 209-N2-2097 { P.O . Bax 108 Contractor Rindahl Drilling_ Address Corning, Calif . 960?tense Ifo. 601535 Phone��-6-82 TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r PUMP INSTALLATION D. SYSTEM REPAIR ❑ OTHER -X Extraction 'j-TA ec&'1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing 88- O Domestic/Private ] Gravel Pack ❑ Tracy Type of Casing Ste e 1 156 wall Specifications M Public ❑ Other Cl Delta Depth of Grout Seal �a r]e s Type of Grout 9 Sac _ I I Irrigation VarieSApprox. Depth I I Eastern Surface Seal Installed by Well Cap _ ti Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 ExtraCti.on Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I 1 DESTRUCTION € I (No septic system permitted if public sewer is available within 200 feet./ Installation will serve: Residence_ Commercial— Other r . 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 i LEACHING LINE ❑ No. & Length of lines Total length/size Q�1 FILTER BED ❑ Distance to nearest: Well Foundation "Property Line �J SEEPAGE PITS l 1 Depth Size Number SUMPS C1 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 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 taws 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. Signed X Title: .,._(� L�7J`'v� Date: J S3 FOR DEPARTMENT USE ONLY Application Accepted by 72?9 Zi� �`? Data--j/�0 i� Area 'f SD Pit or Grout Inspection by Date 3131 J-3 Final Inspection by Date f-3 �f�� 45513, 1414' cat, 4&OAS, 4-7 , X37 , q-17e, 4461 C ).-A)NO.)gL3C Additional Comments: ❑ Stk 466-6781 ❑ Lodi -3421 If Maf(teca 112 -71041 IN Tracy) 5-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 26s� I{K a FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE AERMIT'NO. INFO //)) H +.EH 1324(REV.I i n sl cia � ��,�� EH 11-26 !!! /�-