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• APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 14 ; PERMIT EXPIRES 1 YEAR FROM DATE ISSUED OCT 2 6 1992 (Complete in Triplicate) RNVIRI.,NMENTAL HEALTH Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wf?EWPII Q/IP�'RPP"cation is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and egu I ns an Joaquin Local Health District„�1 � pla . Job Address Sha.rT3e Army Depot City Lathrop Lot size Base PM Owner's Name U. S . Army Address Roth. Rd. Lathrop, Calif. Phone 209-982-2097 P.O . Sox contractorRIndah1 Drilling Address Corning, Calif. 960?'�enseNo. 601535 Phone916-824-01 2 TYPE OF WELL/PUMP: NEW WELL]V WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER M 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4" ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SCh 40 PVC Specifications f"1 Public ❑ Other n Delta Depth of Grout Seal Various Type of Grout neat cemen I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Cement - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 501 Monitoring Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION 1 I INC septic system permitted if public sewer is available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8, Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X I f Title: Or 44-7� Date: FOR DEPARTMENT USE ONLY j� Application Accepted by Date I "r Area Pit or Grout Inspection by yN1 /n.._ Date Fi pb Y nal Inspection by Date 7 Additional Comments: Mwy� I-fR M.) y7R I'YILtJq-lZ _A MW4-7(,Q. MI-Y17-74 MU NC-1 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63850; L Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2009, Stk., CA 95201CK A J-1 S� FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO EH I1NIREV.1/x51 -4gq °° ego /� qa 3b6a- 5N 11-2e