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APPLICATION FOR PERMIT ' SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Y F Telephone (209) 4.66-6781 R��EIVEI� PERMIT EXPIRES 1,YEAR FROM DATE ISSUED i (Complete in Triplicate) AU G += - 1990 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 with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the LFVI%gkliSMOAep ,ipM0476 �W6ijoaquin Local Health District. nrRA�!TIrrn�nrrr Job Address Unocal S/S #5421,. ...7303 Pacific Ave. City Stockton Lot Size PM Owner's Name Unocal Corporation Address 2000 Crow Canyon, San Ramon CA Phone 415/277-2303 Rancho Cordova CA 94583 r ContractorWest Hazmat Address 32 Fitzgerald St. License 0544979 Phone 916/638-7276I TYPE OF WELL/PUMP: NEW WELL 30 WELL REPLACEMENT ❑ DESTRUCTION ❑ ,MW2,M3,IV PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑"' See attached l r Site Plan J i DISTANCE TO NEAREST: SEPTIC TANK 7,100 SEWER LINES ** DISPOSAL FLD. 11QQ---- PROP. LINE FOUNDATION 20 t AGRICULTURE WELL> 100' OTHER WELL PITS/SUMPS 100 t � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11, 211 F-1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing G ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SCH 40 PVC Specifications 0.02" Slot FI Public :P Other(MonitoriTTg6elta Depth of Grout Seal Approx. 50' Type of Grout Concrete s I I Irrigation 7W ._Approx. 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 501 Depth Filler Material (Below 50') — TYPE OF SEPTIC WORK: NEW INSTALLATION C1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is " available within 200 feet.) 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 ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 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 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 laws of California." 9 The applica mu call all re d inspections. Complete drawing on reverse side. Signed �- Title: Sr. Geologist Date: 8/7/90 Jeffrey i , K lian Engineering, Inc. , P.O. Box 996, Benicia, CA 94510 707/746--6915 FOR DEPARTMENT USE ONLY 7 Application Accepte by I __ Date 6 Area > Pit or Grout Inspection by Date 6 L' Final Inspection by Date t Z 0 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 C� RECEIVED BY DATE PERMIT'NO. INFO �r +.EH 13-24(REV.1/H 51 EH 14-28 r