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RESM Job //30003-4 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E: HAZELFON AVE. , STOCKTON , CA Telephone (209 ) 466-6781 PERMIT EXPIRES 1 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 7906 North El Dorado Street City StOCICtAII Lot Size PM ARCO Products Co. P .O. Box 5811 , San Mateo, CA 94402 Owner's Name Address Phone Co Tactor Woodward Drilling Address P .O . BOX 3364 Rio Vista , CA License No. C57-581639 Phone 1707 374 4300 PE OF WELL/ PUMP: NEW WELL M WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SY M PAIR ❑ OTHER )b Monitoring and Vapor ll DISTANCE TO NEAREST: SEPTIC TANK XMI SEWER LINES I DISPOSAL FLD, >M PROP. LINE Z50L FOUNDATION )51 AGRICULTURE WELL _)r,Dr OTHER WELL )501 PITS/ SUMPS )5011 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 PVC Specifications M Public IR Other ❑ Delta Depth of Grout Seal 2 ft Ab0Ve SCreeRlype of Grout RPntinite/fAM t I I Irrigation _. Approx. Depth XI Eastern Surface Seal Installed by driller _ Repair Work Done ❑ Type of Pump H . P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 7 ft ahnye screen X Other 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 •�lV� available within 200 feet. ) Q 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 1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line rye LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 0 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 Dihirict. 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 m 11 for 11 required inspections, Complete drawing on reverse side. Signed X 1(" Stec/ y Title: Date: 4 I( Eloise F . Cherven , Project Geologist 11 - 9119- FOR DEPARTMENT USE ONLY Application Accepted byAoe Date U Area Pit or Grout Inspection by Datefinal Inspection b _ _ Date �y Additional Comments: S AA ❑ Stk 466-6781 ❑ L i 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 nn INFO AMOUNT DUE T AMOUNT REMITTED CASH I RECEIVED 9y DATE ER D U e EH 1a24 IREV. 1 / x51 c;w7yt 1/4? Mf/ L7/ 3/a� EH 14-R