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Lt"\ • APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTONS Telephone (209) 466-6781 ACR OAAQI�JI�NCOLIPM-pUELICHEALT'HSE&,V PERMIT EXPIRES 1 YEAR FROM DATE ISSUdR 0NMENTALHEALTHDMSION (Complete in Triplicate) SPECIAL PERMIT 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 441 blest Charter Cloy CityStockton Lot Size PM Owner's Name ARCD Products Comany Address P.O. Box 5811, San Mateo, CA 94402 Phone (415)571-243 Contractor Wayne Drilling Address P.O. Box 726, I inC01n, CA License No. 376343 Phone 916 645-9355 TYPE OF WELL/PUMP: NEW WELL ff WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK )50 SEWER LINES <50 DISPOSAL FLO. A_ PROP. LINE FOUNDATION )5(1AGRICULTURE WELL )50 OTHER WELL U PITS/SUMPS 'JA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1011 11 Dia. of Well Casing I\ r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing RIC Specifications * Public14Dther 7 Delta Depth of Grout Seal 40 Teat Type of Grout bentonit? Com. t I I Irrigation _bb_Approx. Depth ly Eastern Surface Seal Installed by 'ri11,r Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter 4 inch Sealing Material (top 501 qrn,rS 1/aCCrr/(7rOUn�-WaterDepth 45 t0 5G `! 1'. Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is \ available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Watedpyldruy SEPTIC TANK ❑ Type/Mfg Capacity No. fCfp GPr rJ711!!a&lliihh'� PKG. TREATMENT PLT. ❑ Methbit W4Disp�� d ` Distance to nearest: Well Foundation Property LirA P n,�Q92 LEACHING LINE ❑ No. & Length of lines Total length/ AN Q FILTER BED ❑ Distance to nearest: Well Foundation P o `rl.rnl uC1Jr'J OjVi$'t7Pl SEEPAGE PITS I I Depth Size Number SUMPS L1 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 no employ any person in such manner as to become subject to workman's compensation laws of California." tractor's Ing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shat mploy persons su jec[to workman's compensa- tion laws of California." qo The applicant must I or all required i pections. Complete drawing on reverse side. 6 7. Signed XTitle: PYvJJ2Ct r�e010915t Data: 4 1 L FOR DEPARTMENT USE ONLY 9 Application Accepted byDate / Area Pit or Grout Inspection by / ate "�.,iceG._'Z— nal Inspection by Date Additional Comments: V Xt � • y SAN jOAQ MUMMY-PMC HEALTH SESVIC ❑ Stk 466-6781 ❑ Ladi -3621 ❑ Manteca 823-7104 ❑ Tracy B35-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box� ErlD1 1 INFO AMOUNT DUE AMOUNT REMITTED CARECEIVED 6Y / DATES /T' ..EH 1124 IREV.1/x51 EH 142E CJ