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APPLICATION FOR PERMIT • tAN JOAQUIN 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 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 DepKo'I-Y1 T.athror Lot Size 800 ac . - PM pCity Owner's Name U. S . Army Address Roth Rd. La.thro�) Phone 209-982-2097 P.O . .y0. iva Contractor indahl Drillin75 Address Corni.ng,Ca. 96021 1535 P15-82?-01 2 License No. 60Phone- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O 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 Dia. of Well Casing 411 ❑ Domestic/PrivateTrac Type Gravel Pack ❑ of Casing Sch AO nVC Y YP 9 � Specifications ❑ Public ❑ Other 11 Delta Depth of Grout Seal tfarleS Type of Grout_geat cemen I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well pgstruction I-] WellDiameter Sealing Material (top 50') Pon1uorinrj Depth P Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 7`3 available within 200 feet.) 0 Installation will serve: Residence— Commercial— Other Number of living units: _ Number of bedrooms 57- Character 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 Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS 0 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 subcontracting 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.� v Title: QlAk-7,, i__ Date: FO ARTMENT USE ONLY G Application Accepted by Date 1 Le) Z Z- / a Pit or Grout Inspection b atea.�- Final Inspection by Additional Comments: ❑ Stk 466-6781 ❑ 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, Stk., CA 95201�I FEE AMOUNT DUE AMOUNT REMITTED CK BY BY "I/ S I INFO (ryCA,. DATE PERMIT'NO. • :HH;4283-24(REV.tix51