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• APPLICATION FOR PERMIT SAN JOAOUIN 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 heleby 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. � ) R _ /ter— RA Job Address Sharpe Army Despot city Lathrop Lot Size ease PM 2707 E. Fremont Owner's Name Lyon Communities Address Stockton Calif Phone 209-467-1565 .12 .0 . — — P.G . 3ox 108 Contractor R�-ndahl Drilling Address Corning, Calif . 960ZL,se No. 601535 Phtine 6- — 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER N EXtraetlon 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 [5 Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private 79 Gravel Pack ❑ Tracy Type of Casing Steel- 176 wall Specifications FI Public ❑ Other ❑ Delta Depth of Grout Seal Varies Type of Grout—9--aa-Q _ I I Irrigation farle,ppprox. Depth I I Eastern Surface Seal Installed by 'Jell cam _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Extraction Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 y Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 D3trict. 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 Title: (0 ")- Date: FOR DEPARTMENT USE ONLY r G 2 T Application Accepted by��1 4 Date / /J Area � V Pit or Grout Inspection by �/t� Date f ( 3 Final Inspection by 4'() Date 42/7 1`23 Additional Comments: L�T ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6365 ��CI Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 J'C S �✓ FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. NFO / 2 4EH 13-74 IREV.1/551 EH 14