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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 7607 E. NAZEL i ON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .JAN 11 1990 (Complete in Triplicate) SAN JOAQUIN COUNTY Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install rUQG C HE LTOF I,kstei � made in compliance with San Joaquin Coun�,Y Ordinance No.549 for sewage or No. 1$$2 for well/pump and tion is u es oaquin Local Health District. 5d 0 `< 0411� /j, 'J Job Address 455 East "K" Street cityLathrop _ Lot Size _ PM Houston, TX (713) 464-9451 owner's Name San Joaquin CoGen Limited 9432 Old Katy Rd. Phone Rio Vista, CA (707) 374-2306 Contractor H. L. Camp DrillilAerdQ . P . O. Box 506 License No. 507781 Phone_ TYPE OF WELL/PUMP: NEW WELL XX WELL REPLACEMENT ❑ DESTRUCTION ❑ See Developmen PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ aCi1E'Ci -9O 9 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PRO . LINE it a FOUNDATION AGRICULTURE:WELL OTHER WELL X PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS XIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 7 n © Domestic/Private EI Gravel Pack 'I-] Tracy Type of Casing LT&C: 23# Specifications K-55 N-$0 [I Public XX Other {7 Delta Depth of Grout Seal Si„-rfAc•e/2'D_ Type of GroutCl a$S G Ce_ ent I 1 Irrigation 5300 -Approx. Depth t I Eastern Surface Seal Installed by Contractor Repair Work Done 1: Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION I I DESTRUCTION I 1 {No septic system permitted if public sewer is available within 200 feet.) 0 Installation will serve: Residence Commercial— Other G 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. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L1 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 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 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 applic ust call or r inspections. Co a drawing on reverse side. Signed x -----PtWB r. Environmental En ine@ge_ 7'A-a— _9c_1 FOR DEPARTMENT USE ONLY tt Application Accepted by Date !� rea / Pit or Grout Inspection by Date Final Inspection by to Additional Comments: //4�e ,lt'� ❑ Stk 466-6781 ❑ Lodi 369-3621 / ❑ Manteca 823-7104 ❑ Tracy 835-6385 t+ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 41 INFO CASH I7RECEIVED BY DATE PERM 'NO, ~.1Z4(REV. i n 51 �� "-9