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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA I 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 ounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San Joaquin C Local Health District. Job Address 11 City Lot Size PM Owner's Name ARCO Products'�Com an Address P.O. Box 5811 San Mateo CA phone 415-571-2434 _Ea ne ~Drilling COmpaAMress P. Box 726, Lincoln, �kense No. Phone916-965-935 Contractor Y TYPE OF WELL/PUMP: NEW WELL ❑ . WELL REPLACEMENT El DESTRUCTION © Soil Bo s ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER _ g l 40 s PROP. LINE FLD. – DISTANCE TO NEAREST: SEPTIC TANK. . 20� SEWER LINES DISPOSAL FOUNDATION – AGRICULTURE WELL OTHER WELLS 1000 f0@*S/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j El Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casing Specifications ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout bentonite/ Cl Other ❑ Delta Depth of Grout Seal Cement/water C"1 Public i -Approz.:Depth I I Eastern Surface Seal Installed by I I irrigation Repair Work Done ❑ Type of Pump H P State Work Done V ` _ Well Destruction L] Well Diameter Sealing Material atop 50'1 �ry 4 Depth A Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION l"il REPAIR/ADDITION l 1 .DESTRUCTION i I available`wi within feetsned if public sewer is , Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Water table depth k Character of soil to a depth of 3 feet No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal `) PKG. TREATMENT PLT. ❑ Distance�to nearest: Well Foundation Property.Line 1 .I s i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance nearest: Wel! Foundation Property Line Number SEEPAGE PITS , i I Depth Size Property Line SUMPS L-1 Distance,to nearest: Well Foundation DISPOSAL PONDS ❑ t thereby 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 Diltrict. Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not signature employ any person in such manner as fo become subject to workman's compensation laws of California.'' CpntracBosnSisub subject to wong or �kmanlscompensa certifies the following."I certify that innfthe performance of the work for which this permit is issued,l shall em loy p 1 L f� tion laws of California." t 1V1 The applicant must cal or all required inspections. Complete drawing on reverse side. Signed X Title: Pro'e t Geolo ist Date: , May 14, 1990 Eloise K. Frick rs. F. EPA USE ONLY a Application Accepted by Date Date Pit or Grout inspection by f. Date Final inspection 21 Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Ma eca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 k CK ECEIVED BY DATE PERMIT FEE . f AMOUNT DUE AMOUNT REMITTED CASH RNO INFO fa +.EH 13-24!REV,1i85) EH 14-26