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APPLICATION FOR PERMIT ! SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f (Complete in Triplicate) e work herein described:This application is Application is hereby•made to the San Joaquin ns of the San.Joaquin in Local Health District for a permit to construct and/or install thOrdinance No. 549 for sewage or No. 1862 for welt/pump and the Rules and Regulatio made in compliance with San Joaquin County Local Health District. South of Louise', Northeast of Harlan & cityLathrop -- Lot size 530 acres PM —..-�� Job Address How an see Site Plan i t PhoneE-W-ff.T Owner's Name Libb -Owens-Ford. Com an Address P•O• Box 128 Lath -op,416374 Chgisty street P65 = x+0Drilling - - tddressFremoift CA1' 8-:r3I14 =-itcense Rii.'4 4324 : ` Contractors 5k-,Er seo'E-iron E TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER. , Geotechn�c Y 720' ~SEWER LINES none DISPOSAL FLD.SQQ---PfiOP. LINE SQf- . DISTANCE.TO NEAREST;-SEPTIC TANK310' x AGRICULTURE WELL 4501 OTHER WELL 1��_— PITS/SUMPS IIS2rie FOUNDATION ff INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing I0 Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Type of Casing—UD-U2— Specifications Cemerit/ ❑'Domestic/Private ❑ Gravel Pack 113Tracy Ypf11 death Type of Grout�]ERtOni to fl Public K Other ❑ Delta Depth of Grout Seal full I i Irrigation 20-35 r-Approx. Depth i I Easter Surface Seal installed byY Repair Work Done 0 Type of Pump [,� H P state Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') vJ Depth Filler Material (Below 501 T TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIRIAQDITION l I DESTRUCTION ! I availablerc system wthin 200 feet.)if public sewer,is f Installation will serve: Residence L Commercial Other ( Number of living units: Number of bedrooms Water table depth .O Character of soil to a depth of 3 feet �o SEPTIC TANK El Type/Mfg Capacity No. Compartments Method of Disposal l A PKG. TREATMENT PLT. ❑ ;y� Distance to nearest: Well Foundation Property Line t F LEACHING LINE ❑ No. & Length of lines s Total length/size r FILTER BED ❑ Distance to nearesf: Well Foundation Property Line SEEPAGE PITS l 1 Depth t - Size Number # .., -,p SUMPS Ll Distanceto nearest. Well Foundation -Property Line i DISPOSAL PONDS ❑ ' t I hereby ork will be done in accordance with San Joaquin county ordinances, state law's, and certify that I have prepared this application and that the w rules and regulations of the San Joaquin Local Health Di%trict. 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 employ any'the following: u certify that s the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California," �i The applicant must call for all required inspections. Complete drawing on reverse side. 2 [� Date: A LUJ Ei Signed X Title: Applied Sail Mechanics, Inc. l~OF DEPARTMENT•USE ONLY 835 Blossom Hill�(i3. Jose a � Date - �� ' Area Application Accepted by - IQ11 I. Pit or Grout Inspection by Date Final Inspection by < Date �. Additional Comments: ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 . Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 �•i t FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO 1a +-EH 13-241REV.1/A 51 EH 1448