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APPLICATION FOR PERMIT 1� SAN JOAQUIN LOCAL HEALTH DISTRICT - 'I 1601 E. HAZELTON AVE., STOCKTON, CA j`"I '. L--� Telephone 12091 466-6781 �. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) EP;VIf.GME::TAL HEALTH Application is hereby made to the San Joaquin Local Health District fore permit to construct and/or instill the w .,��yyy�.,�� C P° aesJtA¢Reg=s+�ns of the application is made in alth compliance with Sen Joaquin County Ordinance No.54910 sewage w No.1B621or well/pump and the Rules and Regulations of the San Joaquin Luca)MedhM1 District. Job Address 45 East Harding Way City Stockton Lot Size PM Annabel Lanes Suite 200 Overat Name Chevron U.S.A. Inc. Address San Ramona CA 94583 Phone(415)838-5300 2825 East Myrtle Street Contractor Spectrum Exploration Address Stockton* CA 95205 License No.512268 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER IN 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 ❑Industrial ❑Open Bottom ❑Mamec+ Dla.of Wall Facavation nC Dia.of Well Cain 4—inch 119 Domestic/Private 119 Gravel Pack ❑Tracy Type of Casing SCh 40 PVC Specifications 1'1 Public ❑Other ❑Delta Depth of Grout Seal 39 feet Type of Grout NeatCement IrriUatbn _Apprpe.Depth I I Eastern Surface Saul Inalalled by _ Repair Work Done ❑ Typo of PuDome State Work Wen Destruction ❑ Well Diamette 4—inch Sealing Material top 50'1 _Neat cement and bentonite grout .' \ Depth 62 feet Filler Material(Below SDJ v TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sawar is available within 201 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 Not; Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No.Compartments PKG.TREATMENT PLL❑ 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 Lina SEEPAGE PITS I I DepthSiza Number SUMPS Ll Distance to nearest: Well Foundation Property Lina S� DISPOSAL PONDS Il N r 1 hereby an cregul that I have prepared this application and that the work w01 be done in accordance with San Joaquin county ordinances,state laws,ar 'L rules and regulations of the San Joaquin Local stealth District \ Home owner or licensed agent a signature andies the following:"I argfy that in the performance of the work for which this permit u iswed, shall mol employ any person in such manner as to become subject m workman's compensation laws of California."Contractoes hiring or sub-cis issu nd, signature certifies the following:"I canny that in the performance of the work for which this permit is issued,I shall employ parsoru subject to workman's company tion laws of California." The applicant must" to II ro u'red inspections.Complete drawing on revel")ids. Signed Title: Daum'/ p �/, ✓ FOR DEPART&IENT Un ONLY�Q�/�] Application Accepted by Date Ar" Pit or Grout Inspection by "'"'' �Deta �� Final Inspection by_ Date Additional Comments: - 1 C1flAe%VQz1J/,tl LJ Six 466-6781 Lodi 36 ❑Mang 823-7101 Trac 835- Applicant-Return all cored to:Environmental Health Parmit/Services Trot E.Hazelton Ave., P.O.Boa 2009,Stk.,CA 96201 FEE INFO AMOUNT DUE AMOUNT REMITTED C KSIT RECEIVED BY DATE PERMIT No, •EX Ia]a 1REVnr.ai � / ER INo