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APPLICATION FOR PERMIT z. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZC TON AVE, STOCKTON, CA t Telephone (209) 1 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (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. Lath 135 'x201 ' PM Job Address 85 E. Louise/I-5 City p Lot Size Owner's Narn ARCO Petroleum Address �n P.O. Box 5811, San Mateo, qe415-571-2400 Products Company916-372-27 5 Contractor W.F. Lewis Const.AAPR 506 Glide '.Ave. License No. 348937 phone TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACE ENT ❑ DESTRUCTION 1:1 PUMP INSTALLATION D SYSTEMA REPAIR ❑ OTHER 9 existing DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES .. �.°; - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS�%�a ❑ Industrial ❑ Open Bottom ❑ Manteca �{ Dia. of,:Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casings Specifications ` ❑ Delta " + , Depth of Grout Seal Type of Grout f"1 Public `l Other g�ti: P r I I irrigation --Approx. Depth t I Eastern � .Surface Seal installed by o- Repair Work Done Ll Type of Pump H.P. State Work Done I Well Destruction C] Well Diameter Sealing Material (top Depth ° r Filler Material (Below 50'I TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION t:1 DESTRUCTIO INo septic system permitted if public sewer is available within 200 feet.) r i Commercial -_ Other (new sewer line) Installation will serve: Residence� r r � Number of living units: Number of bedrooms -- Character of soil to a depth of 3 feet: F Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT. Elr , Distance to nearest: Well Foundation Property tine Total length/size LEACHING LINE 171No. & Length of lines r 'FILTER BED ❑ Distance to nearest: Well Foundation Property Line 'I SEEPAGE PITS I I Depth Size Number SUMPS L-1Distanceto nearest: Well Foundation Property Line DISPOSAL PONDS ❑ -' -� 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 DRarict. 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 oll9wing: "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 a iifornia." The applic t t call or all re d i ctions. Complete drawing on reverse side. C' Signed X Title: t7 L`1�Ttc�t Date: 1 FOR DEPARTMENT USE ONLY € R Application Accepted by �� X*' ^r— + Date _ Area t I Dat Pit or Grout Inspection by l�D�atiie��tt Final I is by � ��. Additional Comments: r�' ❑ Stk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,.Silk., CA 95201 t FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY PATE PERMIT NO. INFO -..EH 13-24(REV.i i H 51 � EH 14-2e ��