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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATnand D (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct anherein scribed. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/ules and Regulations of the San Joaquin Local Health District. 1612 Hammpr Lane Stockton r m s„a PM JOU /Auulubb - - - " y — ARCO Products Company P. 0. Box 581 San Mateo, CA Phone415- 571-2434 Owner's Name Address Wayne Drilling AddressP.0. Box 726, Lincoln, Ricense No. 37645 Phone916-965-9355 Contractor TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X7 So 1 bori ng DISTANCE TO NEAREST: SEPTIC TANK5__ 0 _ SEWER LINES lf� 50* DISPOSAL FLD�S __-q'_t- PROP. LINE>50 ft FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications FI Public Ll Other n Delta Depth of Grout Seal Type of GroutCement bent0, I I Irrigation —. Approx. Depth I I Eastern Surface Seal Installed by sl urr Repair Work Done ❑ Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) 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 ❑ 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 Di§trict. 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 mplete drawing on reverse side. Signed X El of se K. Frick &I - a Title: Project Geologist Date: 9-11-90 F R DEP ENT USE ONLY Q Application Accepted by Date ! "'� Area 33 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca B23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 *-EH 13.24 (REV. I/ 115) EH 14-26 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO.