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i APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 R Cg w D PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) AUa I Iggg Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or ins work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump a J�tl1R4sr<U,lations of the San Joaquin Local Health District. �rr�;'�rS�y�1RAAVji��EA Job Address 4707 Pacific Avenue City Stockton Lot Size PM N. California Blvd. , Suite 650 Owner's Name UNOCAL Corporation Address Walnut Creek, CA 94596 Phone (415) 945-7676 Contractor Trace Environmental Address Sacramento, California License No. 511740 Phone (916)638-802 5 TYPE OF WELL/PUMP: NEW WELL 9 WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES 45 r DISPOSAL FLD. NA PROP. LINE -16-L FOUNDATION SFOr AGRICULTURE WELL NA OTHER WELL 1650, PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 5ct L- * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Tracy Type of Casing PvgSpecifications 11 Public ).�Other ❑ Delta Depth of Grout Seal 721.7 Type of Grout C ene/bent-oite I I Irrigation pprox. Depth i I Eastern Surface Seal Installed by _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter " Sealing Material (top 50') Depth Filler Material (Below 50') �} TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION ( I (No septic system permitted it public sewer is (} available within 200 feet.) J 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 Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size _ Number SUMPS L] 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. 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 taws of California." The applicant must call for allrequired inspe ions. C mp ete drawing on reverse side. Signed X Title: Project Geologist Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date sYl� Final Inspection by Date Additional Comments: y',..--.......__. ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 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 RECEIVEl7 BY DATE PERMIT'NO. INFO C SH +.EH 13-24 1REV.1i 8 55 EH 14-25