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1 � APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT T 1601 E. HAZELTON AVE., STOCKTON, CA -;', C'.,- Telephone 12091 466-6781 nL,:',�} 1..+ it .:1t F• 100"PERMIT EXPIRES 1 YEAR FROM DATA , 9�Q, (Complete in Triplicate) [1 iy�D1 [et Application is heieby 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. 1062 fur well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 45 East HARDING Wy. City Stockton Lot Size PM Owner's Name Chevron U.S.A. Inc. Address 2410 Camino Ramon San Rattlo Phoe (415)842-952 3-090 Contractor Speetrttm Exploration Address2825 F- T1Jrrf•lP St gf- t'tiEsense No.512268 Phone(209) 65-8712 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT-1-1 DESTRUCTION ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 150 n Bonom ❑ Manteca Dia. of Well Excavation]OF.& inch Dia. of Well Casing Pq Domestic/Private 181 Gravel Pack 0 Tracy Type of CasingPVC—SCh 40 Specifications I'I Public Ll Other 1-1 Delta Depth of Grout Seal 20 feet Type of Grout neat cement_ I I Inigalion —.Approx. Depth I I Eastern Surface Seal Installed by tremie & p lmp Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction LJ Well Diameter 4 inch Sealing Material Itop 50.1 Depth 45 feet Filler Material (Below 501 Loonestar #2/12 sand ILA TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line P LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shay"p ari'aiC � tion laws of California." ,Ldf' r.- leflEl�1'Pt9E''lYef' `°1' , -.-I The applicant mu i call for all ®required j spections. Complete drawing on reverse side. Signed t" C / 1/�fl Title: /✓ . Date: �'•1�',—��i' FOR DEPARTMENT USE ONLY E Application Accepted by Date —'Z 3 9 Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0 Stk 466-6701 0 Lodi 369-3621 0 Manteca 023-7104 0 Tracy 835-6365 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 INFO CA It RECEIVED 8Y DATE PERMn'NO. r EH 1126(REV.11.5) •'') 1z EH N.2a ^. C: •a .Z/ 3 S 1_t_IS