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• APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA QCT 2 1992 F Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE 'SSU VIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SeRV'C[5 cation is made nlcompl ante with SanoJoaqu nthe SanCounty OrdinaJoaquin Localnce No.549 for sewage or Health District for a INo. 1862 for t to cwell/pump and the Rules and hereint and/or inall the work R gulations of tlhe Sanis t Joaquin Local Health District. � )y -D�17 , City Sharpe(� rrke�p\ot Lathrop Lot Size tease PM Job Address U S . Army Address Roth Rd. Lathrop2 Calif . _ Phone209-982 -2097 Owner's Name P.O. Sox Contractor WRindahl Drilling Address Corning, Calif . 9609-1ienseNo. 601535 Pnone916-824—C1 2 TYPE OF ELL/PUM .1 P: NEW WELLWELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHEF7�(❑ �traCtlOn 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 811 ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casing Steel 180 Wall Specifications ❑ Domestic/Private Gravel Pack ❑ Tracy varies Type of Grout 9—sac M Public 71 Other n Delta Depth of Grout Seal yP varieRR well cap I I Irrigation _rtpprox. Depth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H P State Work Done _ Wellestruc op ❑ Well Diameter Sealing Material Itop 50'1 exMCtlon Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION I ava1F.0ilablerl system per nitted within 200 feet.) if public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: __ Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearer: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 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 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: d G'l�"'i'�-�— Date: l 0 2 I 9 Z FOR DEPARTMENT USE ONLY �2 Date '�"" Area J Application Accepted by ` ,�/?�2, 3 (iyliy_7`-p_ I 1. Data /�f/'T/ ,C_,.J Pit or Grout Inspection by ,u Date Final Inspection by vAlw3 VM1tJ �4 S VEW LIS Ld a- IS /I1 Additional Comments: [I Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca - racy835-6385Stk., CA 95201 V Applicant - Return all copies to: Environmental Health Permit/Service 1601 E. Hazelton Ave., P.O. Bax 2009, p FEECK DECEIVED BY DATE PERMIT NO. AMOUNT DUE AMOUNT REMITTED CASH NFO D QQ pts I9�`(H� 1't 9e— qa-3cplp3 ..EH 13-24(REV.1/x51 J{ �� ' �� • r 11 EH 1426