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NftW APPLICATION FOR PERMIT %,/ SAN JOAQUIN LOCAL HEALTH DISTRItfN'IOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA ENVIRONMENTAL HEALTH DIVISION Telephone (209) 466-6781 SPECIAL PERMIT PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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 &38 E. Mlgal IInE City age Lot Size 75151) sq. ft PM Owners Name Dave Atwater Address P.O. ROX 1207, Ctnrktnn I CA Phone (209) 466-5921 Sub ContractorWayne Drilling Address License No.376.34,, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION L1SYSTEM REPAIR ❑ OTHER IY I`'Ll'Att$111g Well DISTANCE TO NEAREST: SEPTIC TANK WA SEWER LINES DISPOSAL FLD. PROP. LINE ��A FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS iV INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bonom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 ❑ Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing M SChElille 40 Specifications F-1 Public FI Other IN Delta Depth of Grout Seal 10t Type of Groin_ t ��7.�,�,,, I I Irrigation 50_Approx. Deptnh�� I I Eastern Surface Seal Installed by EDM Dn11i� Repair Work Done ❑ Type of Pump —SLA— H.P. WA State Work Done Well Destruction ❑ Well Diameter — Sealing Material Itop 501 Depth — Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if 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: 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 L1Distance 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." Contractors 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." Thea licant ust can for I r SAN )OAQUIN LOCAL HEALTH DISTRICT pp eq 'e ms tions. Complete drawing a^��', arse�siicle ENVIRONMEIN�TAL HEALTH DIViSI QN Signed X C Title: _-L/ �irr'W,, SPECIAL D$t? V G. H. H. for W FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pito Grout In pection by Date Final Inspection by Data 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, Sik., CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. . E1]211REV.vxS) EM 1124