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T � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRIak JOAQUIN LCSCAL HEALTH DISTRICT ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZEL T ON AVE., STOCKTON, CA SPECIAL PERMIT 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 &38E. M4elulM City1kQdUjd2g — Lot Size 75.58[)--- t- PM Owner's Name Dave Atwater Address P-0, Box 1207, Stockton, CA Phone (209.) 466-9921 SUb ContractorWaVne Drilling Address License No._q7634_5_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER CX MalitOrirg Inlell DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES DISPOSAL FLD. PROP. LINE 77�� FOUNDATION AGRICULTURE WELL OTHER WELL 75' PITS/SUMPS WA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4" O Domestic/Private A Gravel Pack ❑ Tracy Type of Casing EW SCh2C111e 40 Specifications 1"1 Public n Other X Delta Depth of Grout Seal 101 Type of Grout I I Irrigation 50..Approx. Depth I I Eastern �TSurface Seal Installed by ` Repair Work Done L7 Type of Pump ILA H.P. NZA State Work Done_ Well Destruction ❑ Well Diameter – Sealing Material (top 50') Depth 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 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 Ll 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 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 JOAQUtN tGCAt_ tlEAr.rta The applicant,�jusst call for I re qu'a ins tions. Complete drawing o er/se si t:NVIR0NM[NTAL H[ALTH DTVI+1 1 Signed X C�/� Title: %/ J�//G / Da V G. H. H. for lire FOR DEPARTMENT USE ONLY Application Accepted byGrout In Date Area Pito pection by Date Y J7 Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 O 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 FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. INFO Gni ♦ EH 13-24(REV,i/R5) EH 14-M