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.4 APPLICATION FOR PERMIT U SAN JOAQUIN LOCAL HEALTH DISTRIffN IOAQUIN.. OC_AUHEALTH DISTRICT '- 1601 E. WAZEL i ON AVE., STOGKTON, CA ENVIRONMENTAL. HEALTH DIVISION �pE�1AL PERMIT {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 838 E. �bkel le City Woo Lot Size 25,,5[T_ PM Owner's Name Dave Atwater Address Phone (209.) 466-5921 Sub Contractor-Wayne Drilling Address License No. 376345 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER cX Mxdtdl7-g Well DISTANCE TO NEAREST: SEPTIC TANK IVA SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 75' PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Orr 1:1 Industrial ❑ Open Bottom 1-1MantecaDia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing FVC Scl x ule 40 Specifications ❑ Public 171t Other IX Delta Depth of Grout Seal 10 Type of Grout �lt� I 1 Irrigation 5WApprox. Depth 11 Eastern Surface Seal Installed by L2 Repair Work Done L1Type of Pump N/A -- H,P. N/A State Work Done Well Destruction 0 Well Diameter Sealing Material (top 50'1 Depth — Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ) DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.i 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 ❑ - - Jd 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, rules and regulations of the San Joaquin Local Health DiWict. 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." SAN JOAQUIN LOCAL HEALTH DISTRILI' The applicannt,Must call for I req 'e ins tions. Complete drawing o erre si g/ —/ENVIRONMENTAL HEALTH ©lVsSl N Signed X ll Title: �L/r:/6� SPECIAL pa�te� G. H. H. Tlgineeririg for W FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit o Grout In pection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 623-7104 ❑ Tracy 635-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATEPERMIT-ND. INFO S�Ht L/ . EH 13-21(REV.t/x 51 ��0 �oo EH 11-28