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• APPLICATION FOR PERMIT • N 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 Rules and Regulations of the San Joaquin Local Health District. Job Address Sharpe Army Depot City Lathrop Lot Sae 600 AC PM Owner's Name U.S. ilrmy address Roth Rd Lathrop , Ca.• 209-9 2-20971 P.O . ox Contractor Borth Va.11ey DriJ4Wj5 Corning, Ca. 96021 License No. q'15834' Phone 216-824-0162 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)p -Cxtraction 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 ❑ Open Bottom }Q Manteca Dia. of Well Excavation Dia. of Well Casing 8- 8 ❑ Domestic/Private [k Gravel Pack ❑ Tracy Type of Casing Steel Specifications (9 Public f7 Other Ll Delta Depth of Grout Seal 1-00, Type of Grout track s1U I I Irrigation 135Approe. Depth I I Eastern Surface Seal Installed by Cement _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter �� 8-11 Sealing Material (top 50') 9 sack s1Llry .Extraction Depth 137 ' Filler Material (Below 501 8 mesh Sand _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is r ^ available within 200 feet.) v \1 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 _'1t•J SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1� 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 1 I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I hav6 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 dgent'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." Contractors 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 oat call fnr all required inspectip a . Complete drawingooy;vrse side. �/ Signed X Title: ! Date: 3 - 144 — 7 6 F A T USE ONLY Application Accepted by Date 3 e Area 33 Pit or Grout Inspection Date v Final Inspection 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, Sik., CA 95201 FEE A EH 13711REVi/x m NFO AMOUNT DUE MOUNT REMITTED Me". RECEIVED BY DATE PERMIT NO. • . O,� EH 167a � ,, _<;-�-3