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t, APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON 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 Size PM U.S. ARMY TOXIC AND Owner's Name HAZARDOUS MATERIALS AGENCA-gdress ABERDEEN PROVING GROUND, MD Phone 21010-5401 (916) Contractor RINDAHL & YEAGER DRI"k4p P.O. BOX CORNING, 071—License No. 498977 Phone 824-0162 TYPE OF WELL/PUMP: NEW WELL NONITOR WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 1011 Dia. of Well Casing �r EX Domestic/Private CXGravel Pack ❑ Tracy Type of Casing PVC Specifications PORTLAND ❑ Public ❑ Other ❑ Delta Depth of Grout Seal VARIABLE Type of Grout CEMENT ❑ Irrigation _Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter 411 I.D. Sealing Material (top 501 PORTLAND CEMENT/BENTONITE Depth VARIABLE Filler Material (Below 501 SAND (SCREEN AREA) OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will s 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 :Well Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: dation Property Line LEACHING LINE ❑ No. & length of lines �Iength/size_FILTER BED ❑ Distance to nearest: Well Foundation SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 compens6- tion laws of California." The applicant must call f r all requir inspections. Complete drawing on reverse side. Signed Title: AE5 X, ry ®4 a v5 Date: 4.�FORPARTMENT'LSE ONLY Application Accepted by Date _® 7 47 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Enviro ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, k., CA 95201 ® } FEE AMOUNT DUE AMOUNT REMITTED # RECEIVED BY DATE PERMIT'NO. :® INFO CASH EH 13-24(REV.1/8 5) `� 1�]/ —n r. .r_ < /