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APPLICATION FOR PERMIT �A SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA PAYMENT Telephone (209) 466-6781 RECEIVED PERMIT EXPIRES 1 YEAR FROM DATE ISSUE!bEC 2 0 1989 pp y AWJ0AiQUlNCOUM{ .` � dAN J A%IN COU pp Application is heieb made to the San �ruct and/or in I his application is made in compliance with San Joaquin r �nanc o. r se a e of No. 8 for I/pur��mkd s�n ��+ TfflI&San Joaquin Local Health District. IttV J iJ Job Address 4707 Pacific Avenue City Stockton Lot Size PM 2175 N. California Ave. Owner's Name _ Unocal Urnoration Address Wa1n,TtCreek, CA 94.59.6 Phone Contractor Spectrum Exploration AddR-9. 2825 E. Myrtle, Stockt(ense No._51� 22.6B Phone —134-5 OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ - — SYSTEM REPAIR ❑ OTHER ffFive monitoring we lso) DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 10 1 9 20' 9 20 OSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation IU inch Dia. of Well Casing 4 inch ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasinOlyyinyl chl. PVC S$@""fibns Cement/bento ite Ll Public Other 15 f4't""❑ Delta Depth of Grout Seal a112rox 35 ft, Type of Grout,5_lairry _ Irrigaap' n. Approx. Depth I I Eastern Surface Seal Installed by SnPrtrumx�� c_,,,_,_. _ e a r r Mne ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 "tel,y Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION l 1 INo septic system permitted if public sewer is x� available within 200 feet.) Installation will serve: Residence_ Commercial_ Other d Number of living units: Number of bedrooms J 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 ❑ No. & Length of lines Total length/size ' FILTER BED Cl Distance to nearest: Well Foundation Property Line k 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 DMrict. 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 applican us call for all req .red i pec' ns. Complete drawing on reverse side. Signed X Title: _7- X_ n= Date: I``♦ L�/ FOR DEPARTMENT USE ONLY e Application Accepted by Data Z Area i Pit or Grout Inspection by Date�.r�'0 Final Inspection by data 3 +� Additional Comments: ❑ Stk 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT'NO. INFOEK 13-24 /// EH 1428(REV.i/n5) ^ � � 110 `Z—>— C' c7 ra