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t S �- APPLICATION FOR PERMIT : SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE.; STOCKTON, CA Telephone (2Q9),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 whh 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 DistrictA f r ' Job Address I664--Pacific Avenue City Stockton Lot Size PM 2175 N. California Ave. , Suite 650 Owner's Name _UNOCAL Corporation Address Walnut Creek, CA 94596 Phone 415 945-7676 w Contractor. Address 2825 E. Myrtle St. , StOLkUMNo, 512268 Phone (209) 465-8712? TYPE OF WELL/PUMP: NEW WELL K PLJ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑LJ 4-5. 'SYSTEM REPAIR ❑ OTHER ❑ j DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES 60 FT DISPOSAL FLD. NA PROP. LINE 10 FT FOUNDATION 15 FTAGRICULTURE WELL NA OTHER WELL 1000 FITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial El Open Bottom ❑ Manteca - Dia. of Wel{ Excavation Dia. of Well Casing 2rr ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Sched 40 Specifications l`l Public LOther Monitor C1 Delta Depth of Grout Seal 17 FT Type of Grout neat cement I i Irrigation ,j_ZApprox. Depth 1.1 Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material (top 50'1 �- Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION 1 1 DESTRUCTION I ] (No septic system permitted if public sewer is kavailable within 200 feet.) Installation will serve: Residence— Commercial— Other r 4 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet-'I Water table depth SEPTIC TANK _ ❑ Type/Mfg! Capacity No. Compartments r PKG.. TREATMENT PLT. ❑ Method of Disposal 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 I SEEPAGE PITS I l Depth I Size _ Number SUMPS ❑ 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 District. - -- h 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, 1 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." w - The applicanmust calf for all required inspections. Complete drawing on reverse side. Signed x Barr Marc4*e. Project Geologist 11/21/88 � Date: FO PAR T USE ONLY Application Accepted by � Date r rea Pit or Grout Inspection by ate Final Inspection by G Date/ Additional Comments: ❑ Sik 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environrnental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDH RECEIVED BY DATE PERMIT'NO. � INFO +.EH13-24 iREV.r i n 51 EH 14-29 .l7Ca S ` T/9q h