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APPLICATION FOR PERMIT ti <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT J <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> MAX PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> 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 <br /> Local Health District, <br /> Job Address 30.11 Benjamin Halt Drive City Stockton Lot Size PM <br /> P.O. Box 4023 <br /> Owner's Name Shell Oil Company Address Concord, CA 94524 <br /> • _ Phone (415) 451--2799 <br /> Contractor Spectrum Drilling Address2825 E. Myrtle StocktonLicense No. 512268 Phane465—$712 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LX <br /> PUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ OTHER ❑ <br /> f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 12 Dia. of Well Casing 411 <br /> Q Domestic/Private k-1 Gravel Pack ❑ Tracy Type of Casing_ PVC Specifications <br /> I'1 Public Cl Other Cl Delta Depth of Grout Seal 51 Type of Grout ,4ment/Bent nite? <br /> I I Itrigation 2-6.'Approx. Depth I I Eastern Surface Seal Installed by Trace Environmental <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction 6d Well Diameter Sealing Material (top 501 <br /> (4) Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is 11 <br /> available within 200 fact.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No..R Length of lines + 1 <br /> Total length/size J <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS F) # <br /> 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 <br /> rules and regulations of the San Joaquin Local Health Ds%trict. <br /> 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> Signed Harr Marcu!Title- - Project Geologist pate_ August 14, 1989 <br /> FO ARTMENT USE ONLY ' <br /> Application Accepted by <br /> Date .Area <br /> Pit or rout nspection by c ate Final Inspection by Date <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Man! 623-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY 111 <br /> INFO DATE PERMIT•NO. <br /> +-9H 12.2/(REV.I r x ss Cl <br />