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Filed By: McKesson Environmental Servos APPLICATION FOR PERMIT 6363 Clark Avenue Dublin, CA 94568 SAN JOAQUIN LOCAL HEALTH DISTRICT (415) 828-1446 1601 E. HAZELTON AVE., STOCKTON, CA ATTN: R. Fehler 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 (Acme Galvanizing) 540 W. Scotts Ave. city Stockton Lot Size PM Owner's Name Ms, Sheridan Randolf Address 3564 Gresham Ct. , Pleasanton Phone 415/846-4765 Arrowhead Septic Tank Contractor's Name Datum Exploration License No. 307 313 Phone 415 930-8450 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X Monitor Wells DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation 5-inch + Dia. of Well Casing ❑ Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing PVC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 10 to 15 ft. Type of Grout Cement ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by Driller Repair Work Done ❑ Type of Pump NA H.P. NA State Work Done 1 Well Destruction ❑ Well Diameter Sealing Material (top 501 Cement CJI Depth An-p _Q1L 35 ft. Filler Material (Below 501 Sand S TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is V 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 LAL PKG. TREATMENT PLT. ❑ Method of Disposal 0 Distance to nearest: Well Foundation Property Line .Y N LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance-to nearest: Well Foundation Property Line ,GGry SEEPAGE PITS ❑ Depth Size Number A SUMPS ❑ 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." The applicant m all or t r fired ins actions. Complete drawing on reverse side. Signed Title: �� A'7i7-� ///lLiirt�f -tL Date: �V FO E ENT USE ONLY Application cept Date as -/ Pit or rout In ion by at-e" Inspection by Date i Additional Comment ' tk 466-6781 ❑ Lodi 369-3621 ❑ Manta 823-7104 ❑ racy 8356385 AOM•scl�al��i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 INFO AMOUNT DUE AMOUNT REMITTED RAH RECEIVED BY DATE PERMIT N0. a EH 124 fREV. 101831 - X13 ..O" '�\ t. C 3F5S -\17to EH 1426