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rf G S filar i APPLICATION FOR PERMIT 3 704 �- wn t SAN JOAQUIN LOCAL HEALTH DISTRICT . ' 1601 E. HAZELTON AVE., STOCKTON, CA I Telephone (209) 466-6781 �1 OAQUIN LOCAL HEALTH DIsma PERMIT EXPIRES 1 YEAR FROM DATE ISS IRONMENTAL HEALTH DIVISION (Complete in Triplicate) SPECIAL PERMIT i 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,Y Job Address City Woo dbri d�P Lot Size 194x 148 PM ARCO Products om an Address P.O, hone 21 - Owner's Name 900 1-0570 P.O. Sox 725 License No.- 37634Zphone 7 Contractor Wayne DrillingCo. Address . - - TYPE OF WELLIPUMP: NEW WELD WELL REPLACEMENT 1-1DESTRUCTION171Vappor survey II PUMP INSTALLATION ❑ SYSTEM REPAIR 1-1OTHER ❑ 3 boringfmonitorwe I sg t r 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' Dia. of Well Casing ❑ Donlestic(Private IR Gravel Pack 13Tracy Type of Casing PVC, Specifications l a �,,oring wells ❑ Other n Delta Depth of Grout Seal 8 feat _ Type of Grout_.Neat ckmeat N! I I Irrigation Approx. Depth 1 1 Eastern Surface Seal Installed by fl Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction El Well Diameter Sealing Material (top 501 't Filler Material (Below 50'1 �- Depth C TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION I 1 avao septic system ilablewithin 200 fe tined if public sewer is installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms i '! Character of soil to a depth of 3 feet: Wat c y SEPTIC TANK O Type/Mfg Capacity ?6j No. tments PKG. TREATMENT PLT. C1 Method ofiffsal _ f Distance to nearest: Well Foundation Property Line lw�LiVlr'•1_ Y'y L-r1�I � f LEACHING LINE ❑ No. & Length of lines Total length/size PFIRW FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth ,Size Number SUMPS -Ll`Distance to nearest: Well Foundation Property tine DISPOSAL PONDS Q 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 a rules and regulations of the San Joaquin Local Health District. llowing: "I certify that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the to 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." 1 The applicant must call for all quired in tions. Compete drawing an reverse side nJT ,µe�.��,MS Signed Title; Date: - DEPA NT USE ONLY ` z Zu Application Accepted by Date v� Area J Pit or Grout Inspection by Date Final Inspection by ate v Additional Comments: i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 f Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 CK l�lli FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO ♦.EH 13-24(REV.1 5) EH 14-26