FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT OAN JOAQUIN LOCAL HEALTH DIST O P y 1601 E. HAZELON ON AVE., STOCKTON, CA Telephone (209) 466-6781 �— PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is heteby 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 25775 South Patterson Pass Road City Tracy Lot Size PM Owner's Name ARCO Products Company Address P.O. Box 5811 , San Mateo, CA Phone 415-571-2434 Contractor Wayne Drilling COmpatress-_P.O. Box 726, Lincoln, E enseNo. Phone 916-965-935 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER U Soil Borings DISTANCE TO NEAREST: SEPTIC TANK 20' SEWER LINES -- DISPOSAL FLO. 40' PROP. LINE FOUNDATION AGRICULTURE WELL -- OTHER WELLS- fE rtS/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 PI Public ❑ Other n Delta Depth of Grout Seal Type of Grout bentonite_ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by cement/water Repair Work Done ❑ Type of Pump H.P. State Work Done _ Cn V l Well Destruction ❑ Well Diameter Sealing Material (top 5011, Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 leet.l 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 rl 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 J 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 Dt3trict. 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 canities 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." v\ , The applicant must cal or all required inspections. Complete drawing on reverse side. V� Signed X— o`-- � Title: Project Geolo ist Date: May 14, 1990 Eloise K. Frick EPAeUSE ONLY _ 77 Application Accepted by Date a / Pit or Grout Inspection by Date Final Inspection Date Additional Comments: A ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Me 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. CK 11 1 INFO / ♦.EH 1724 IREV.t/x5) EH 1/-]d