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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address Defense Depot Tracy Chrisman Rd. City Tracy, CA Lot Size 448 Arras PM US Army Office of Records Owner's Name Coro. of Engineers Address 650 Cnpi tal MAI I � qnr Phone9 6-440-2407 Contractor Radian Corp Address 1 95 01 A PI ararvi 7 7 o tzaLicense No. NA _Phone9 — — TYPE OF WELL/PUMP: NEW WELL J0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE See Encl. 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS See Encl. 2 ��/ Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing C. Domestic/Private ❑ Gravel Pack IR Tracy Type of Casing ��P ^7�� Specifications C Public Other See Enc 7q ❑ Delta Depth of Grout Seal Type of Grout C. irrigation �4pprox. Depth" 0 Eastern Surface Seal Installed by I�epalPbfikl;g - Type of Pump N A`" H.P. 'V�A" State Work Done i" Well Destruction - Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) r` Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: table depth y SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ._ Distance to nearest: W I F ation Property Line LEACHING LINE ❑ No. & Length of line Total length/size FILTER BED G Distance to st: Well Foundation Property Line SEEPAGE PITS _ Depth Size Number SUMPS Distance to nearest: Well Foundation Property Line SAL PONDS ❑ 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 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 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 applican st call for al rel'q ITB ins ctions. Complete drawing on reverse side`. 1 Signed X '1+1.�t.Bl_ Title: 147�TT_kJJ all�_ Date: ( �47 -�F(c�1V DEPARTMENT iUSE ONLY Application Accepted by 'rG-z (.��-r'�—. Date Area /7 Pit or Grout Inspection by .—(-// qy _natty /L'`�a}'Final Inspection by Additional Comments: " Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 racy 8356385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk., CA 95201 FEE INFO AMOUNT /DUE AMOUNT REMITTED CASH RECEIVED BY I DATE PERMITNO. EMt3-24 ate IREV.) 85) "f 13 C -1