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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA rift Telephone (209) 466-6781 PERMIT EXPIRES 'I"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 1612 Hammer Lane city Stockton Lot Size PM Owner's Name ARCO Products Company Address P. 0• Sox 5811 , San Mateo, CA Phone415- 571-2434 Contractor Wayne DrillingAddressP•0, Box `726, .Lincoln, C4-icense rVo.37645 Phone916-965--9355 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER YJ Sol l boring DISTANCE TO NEAREST: SEPTIC TANK SO- } SEWER LINES $y 50*DISPOSAL FLO$- PROP. LINE�O ft FOUNDATION AGRICULTURE WELL OTHER WELL- PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.Casing Q Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f"7 Public ❑ Other n Delta Depth of Grout Seal Type of Groutcemen bent0 1 to I,I .Irrigation _-.Approx. Depth LI Eastern Surface Seal Installed by slurry Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 Depth Filler Material (Below 50'1 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION-1 1 INo septic system permitted if public sewer is z available within 200 feet.) , Installation wilt serve: Residence— Commercial_ Other Number of living units: Number of bedrooms µ 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 9 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Diltrict. 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 required inspections. C mplate drawing on reverse side. Signed X Eloise K. Frick xlz, Title: Project Geologist 9-11-90 Date: R DEP ENT USE ONLY Application Accepted by Data d R '9 Pit or Grout Inspection by Date Final Inspection b Date, Additional Comments: - ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE A RUNT REMITTED C RECEIVED BYDATE PERMIT"NO. INFO SH +. /0 -7Wqg EH13-241REV.I/Hs) EH 14-2e V � F I