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APPLICATION FOR PERMIT 1 " SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1"YEAR FROM IDATE ISSU _ {Complete in Triplicate} i" Application is hereby made to the San Joaquin Local Health District for a permit to construct an r' t herein scribed. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/p: and 7e Rules and Regulations of the San Joaquin Local Health District. Job Address 1612 Hammer Lane City Stockton Lot Size PM !'r Owner's Name ARCO Products Company Address P. 0. Box 581' , San Mateo, CA Phone415-- 571-2434 1 Contractor Wayne Drilling AddressP•0. Sox 726, Lincoln, A-icense Into, 37645 Phone916-965-9355 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X3 Soil boring DISTANCE TO NEAREST: SEPTIC TANK>5-_-._ _ SEWER LINES If?50k'DISPOSAL FLD�5�_+ PROP. LIN050 ft FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'r r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION;SPECIFI CATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications 11 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout cement bento I I Irrigation —.Approx. Depth 1 l Eastern Surface Seal Installed by slu= ' Repair Work Done ❑ "Type of Pump N.P. I{; State Work hone_ Well Destruction ❑ Welt Diameter Sealing Material (top 501 !3 Depth Filler Material 18elow 50'1 !� a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION'l I (No septic system permitted if public sewer is i available within 200 feet.( f Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms ip 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 FoundationProperty Line j 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: 1 certify that in the performan le of the work for which this permit is issued, I shall not I 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 fallowing: "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 Eloise K. Frick Title: Project Geologist Date: 9-11-90 R DEP ENT USE ONLY ' Application Accepted by Date / '`� – Area 33 Pit or Grout Inspection by Date Final Inspection by Date i. Additional Comments: ❑ Sik 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 IFEE NFO AMOUNT'DUE AMOUNT REMITTED C if RECEIVE&SY DATE PERMIT'NO. a-EH 7721[REV.f/x5r EH 74-28 .