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65 War K APPLICATION FOR PERMIT 3700 q --1 k'.. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 )OF.QI_!IN LOCAL H(-1L.T}I f)ISTRiCI PERMIT EXPIRES 1 YEAR FROM DATE ISJIl?ON1v{c;`*11',1L iiE:,^il.TFI t�I�'I>;i��i (Complete in Triplicate) SPECIAL C,: FFRLIMH 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 vP Corner Ma' c* >. Tnrli ana Sr City Woodbri dae Lot Size 194x148 PM Owner's Name ARCO Products CanAddress Phone(213) 48 -- P.O. Box 725 900 1-0570 Contractor Wayne Drilling Co. -AddressT incooln, CA 95648 License No.--3-7-63-4 —� Phone(916) 885-2 7 TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT Ll DESTRUCTION H Vapor survey. PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER n 3 boring/monitor sg DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE jFOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation1_4Zi Ch__ Dia. of Well Casing [I Do n)estic[Private [X Gravel Pack El Tracy Type of Casing PVC, Specifications\ iCl r>. oring wells n Other n Delta Depth of Grout Seal _8 feet Type of Grout Ne t_cemEnt I I Irrigation —_ Approx. Depth ( I Eastern Surface Seal installed by — --- S Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50') -- -- -- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i (No septic; systern permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms f. Character of soil to a depth of 3 feet: Watpirtabla depth SEPTIC TANK ❑ Type/Mfg Capacity No.,q,ompanments -`T— PKG. TREATMENT PLT. ❑ Method of,pigposal Ws Distance to nearest: Well Foundation Property Line e 1 LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED LI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth __ _Size _—__— Number _— O SUMPS 1-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS n 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 must call for all quired ins tions. Complete drawing on reverse side �T 14Vy4,.e Signed Title: Data: YGIVIDEP NT USE ONLY f s !�/ ) �"" D Application Accepted by ate Area_ � r te /A Da _�)y Final Inspection by ��y�-mate v Pit or Grout Inspection bye= Additional Comments: ❑.Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO _ CASH ``�� r`�� • EH 13.2/(REV.t i n S � r ✓/1 9v, EH 14-26