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` APPLICATION FOR PERMIT F i F S SAN JOAQUIN LOCAL HEALTH DISTRICT E 1601 E. HAZE T ON AVE., STOCKTON, CA ` Telephone (209) 466-6781 PERMIT EXPIRES TYEAR 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 4 Local Health District. Southeast Corner of Job Address Squires and Harlan Roads City Lathrop Lot Size 176 Acres pM 2707 East Fremont (209) I� Owner's Name Verner Construction Co. Address Stockton, CA 95205 Phone 467-1561 3855 North Business Center Dr. (602) Contractor Tracer Research Address Tucson, AZ 95705 —License No. NIA Phone 888-9400 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ *SEE ATTACH PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Er- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL -.PITS/Sum PS-- - * - -� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f .r i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ! M Public Cl Other n Delta Depth of Grout Seal 7 fL7 Type of Grout b 1,' Y o _ I I Irrigation _-Approxi Depth I I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ k Well Destruction ❑ Well Diameier Sealing Material itop 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION t I DESTRUCTION ( I (No septic system permitted if public sewer is C-- available within 200 feet.) j Installation will serve: Residence_ Commercial_ other f Number of living units: Number of bedrooms k Character of soil to a depth of 3 feet* Water table depth I SEPTIC TANK ❑ Type/Mfg Capacity No. Compo mentsf1e 1 r �lyy PKG. TREATMENT PET. ❑ ,.� t'1t thud o1 1 r5&1 t 4 F1�1}.+T 40?- Distance;to nearest: Well Foundation Property,Line LEACHING LINE ❑ No. & Length of lines Total length/size )U l\k I FILTER BED ❑ Distance to nearest: Well FoundationProperty Line i-1 �NI710 SEEPAGE PITS I 1 Depth Size Number t!�1. 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 Joaqu'i'n 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." Contractors hiring or sub-contracting signature certifies the follow) g: "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 Calif rnia." I� The applicant call for all r�gyired' cti C drawing on reverse side. Signed X , Title: Corporate Manager Date: j`aY 26, 19$9 (Tracer) ( FO EPARTMENT USE ONLY L Application Accepted by i - date Area - / Pit or Grout Inspection by l Date Final Inspection by Date Additional Comments: rn �i Li-J44,ny� " WGS_ . .4;6 �?k T/If-r 6LO t4�, m}i' 5 ❑ Stk 466-6781 ❑ Lodi 36973621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 S f✓2/1 i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 ` 1 f FEE AMOUNT DUE t AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. II INFO l +.EH 13-241REV. 14 51 - EH 14-29 \U O tel\ I F f