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APPLICATION FOR PERMIT �,/ SAN JOAQUIN LOCAL HEALTH DISTROW JOAQUIN LOCAL HEALTH DISTRIC' 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 hereby made to the San Joaquin Local Health District for a permit to construct and/or install the workherein�tiescribed.This �pplicatign 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 Stan Joaquin Local Health District. �a�..;;,,yy,,,,,, Job Address 838E' hblga7.ulrm City��''yy.j c. Lot Size 25,W Sq ft- PM Owner's Name Dave Atwater Address P.O. Box 1907, Stockton, CA Phone SUb ContractorWayne Drilling Address License No.,��, Phone TYPE OF WELL/PUMP: o NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER I Mxdtor1Ig Well DISTANCE TO NEAREST: SEPTIC TANK WA SEWER LINES DISPOSAL PLD. PROP.-LINE. _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS &A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8_1Dia. of Well Casing V ❑ Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing SCI1911le 40 Specifications F1 Public ❑ Other lX Delta Depth of Grout Seal lot Type Type of Grou* �1 �+to W I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by �Tailh e _ Repair Work Done L3 Type of Pump WA_ H.P. N/A State Work Done_ Well Destruction ❑ Well Diameter — Sealing Material (top 50') Depth — Filler Material (Below 501) TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I fNo 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: 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 ❑ Distance to nearest: Well Foundation Property Line 01 DISPOSAL PONDS Cl 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 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." SAN JOAQUIN LOCAL HEALTH DISTRICT The applicant.Aust call for 1 req a ms tions. Complete drawing orN��y/errse�si/��erJTLENVIROCNMw-ENT,rA�L HEALTH DIVlSI N Signed �l Title: %/(�J�L�G/!✓ SPECIAL 'Du m G. H. H. 46remxg for W FOR DEPARTMENT USE ONLY n � Application Accepted by Date o`v Area Pit oGrout I ction 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 H"Ith Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE: AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. . EH 13-24 tREv.l.xs� EH 1 �_OO 42a