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APPLICATION SAN JO QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby glade to San Joaquin County for a permit to construct and/or install the work herein described. This application is glade in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address DDRW - SHARPE 700 Roth Road city Lathrope bot Size/Acreage Owner's Name Defense Logistics Agency Address P.O. BOX 960001 Phone (2091992-7091 (510) Contractor Greg Drilling & Testipglress 950 Home Road License No. C-5748:5465 Phone 313-5800 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION M Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES 100, DISPOSAL FLD. NA PROP. LINE 5001 FOUNDATION501 AGRICULTURE WELL NA OTHER WELL NA PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation-8 i 33Ch Dia. of Well Casing 2 inch Cl Domestic/Private r Gravel Pack X] Tracy Type of Casing PVC Specifications--Srh 40 Il Public fl Other P Delta Depth of Grout Seal R1 Type of GroutNeat Cement I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by NA Repair Work Done ❑ Type of Pump NA H.P. _ St to Work Done_ Well Destruction ❑ Well Diameter 2 inch Sealing Material 8 Depth N \ Depth 35, Filler Material L Depth NA m C TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 i7 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line {tea SEEPAGE PITS 11 Depth Size Number $ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 County 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 workmen'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 applicant must call for all required inspections. Complete drawing on reverse side. Signed f ' �',1- �1 . lil1 _ Title: 12rJjPrt Rngineer Data: February 19, 1997 �i FOR DEPARTMENT USE ONLY Application Accepted by Date Z.f. Area UQy„62c � Pit or Grout Inspection by ,.� -.//--_�� D� ate Final Inspection by Date Additional Comments: � &04-J�-C�Uvv-� •"I U+! 4704 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE�}Q INFO AMOUNT DUE AMOUNT REMITTED C H RECEIVED By DATE PERMIT'N0. v /�/ Page 13A EH 1I 24(REV.rix sr G�0 J Plq ,,L p/��l A,/��- EHlaal �6-� G( / 0