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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ""In HE L 1601 E. HAZEL T ON AVE., STOCKTON,-CA '6. : ,4 k Telephone (209) 466-6781 '` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 CT 2 6 1992 (Complete in Triplicate) 'Mlr,cONMENTAL HEALTH It Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w� � /( QPPlication is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules PEMegu a{i-o�n`s°dfl{ *5an Joaquin Local ealth District` ,� 6"--01 r Job Address Sharpe 'Army Depot City Lathrop Lot Size Base PM Owner's Name U• Army Address Roth Rd. Zathrop, Calif.. phone 209--982-2097 P.O. Box 108. Corning, `Calif. 960?i�ense No. 601535 Phone916-824-01 2 Contractor Rdalil Drilling Address TYPE OF WELL/PUMP: NEW WELL)V WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N1 Monitoring ,.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 411 -❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavationlc� Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Sch. 40 PVC Specifications l"1 Public Ll Other ❑ Delta Depth of Grout Seal varim Type of Grout neat cement I I Irrigation Approx, Depth l I Eastern Surface Seal Installed by C' me, - . 9 r Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Stop 501 P MOnit.Orin -- g Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence Commercial Other i' 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: Wel! Foundation Property Line " LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ ,I Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 1 Depth Size Number i SUMPS Ll Distance to nearest: Well Foundation Property Line r 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 laws of California."Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa 1 tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X 'I r Title: !�"'� Date: Ji FOR DEPARTMENT USE ONLY is Application Accepted by Date .`�tA "� ! Area w 0 Pit or Grout Inspection by Date Final inspection by v+l Date �+ Additional Comments: �U � r 41�r r` mW t4-71 -m'w qj� -A Mw LF1(A �� 121 W N�- ❑ 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 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH () +.EH 13-241REV.1/n 51 EH 1428 lJ