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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 -+ ' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> 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 <br /> Local Health District. <br /> 1 ?!l <br /> COC1,11 <br /> Address —�'3r City Manteca Lot Size PM <br /> ner'sName Atlantic Richfield Address P•O. Box 5811 San Mateo Phone 415-571-2400 <br /> ntractor W.F. Lewis Const Address 506 Glide Ave. W.SalLicense No, B-348937 Phone916-372-27 5 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is --� <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial____ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal O <br /> Distance to nearest: Well Foundation Property Line cab <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS © .��Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line. <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county orcAnapeotuot.la►hrs, and <br /> rules and regulations of the San Joaquin Local Health District. EN <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for y�fs.pe�??it�is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contract Ej f{/1�Jg9 o sg o7�n=signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons sub�e6t pensa- <br /> tion laws of California." <br /> The applic ust ca for all req ' tion . Comp to drawing on reverse side. <br /> Signed Title: Agent for ARCO _. . Date: 9/8/86 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by I �{/l.ri Date Area <br /> Pit or Grout Inspection by ry Date Final Inspection by .P/(- �Date <br /> v�l� E J-�•ll d <br /> Additional Comments: 1 I' -5 0 Ufo P_ri t - - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 13 Manteca 823 71a ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEELAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> 57 <br /> + EH 13-24 1REV.1/$5) Y"I rj� b- 1100 <br /> EH t4-2a 1 <br />