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APPLICATION FOR PERMIT - SAN JOAQUIN LOCAL HE 1601 E. HAZELTO ACTH DISTRICT PE Telephone (2o9E' 6-6..1 ON, CA RMIT EXPIRES 1 VE 1466'6781 tical inApplicaion is COM °mPlanrcby - San the San Joaquin Lo 'Complete S AR FRQj�I PATE IS SUED Health a wuh Joaquin Court cal Health In Triplicate) District. N Ordinance District for a ce No.549 to'sewage orr Nit o. 1 oo2 eruct and/or install t w Job Address 30 j j well/ Ben ' PumP and th ork ei e _ ed. This aurin Holt Drive d application is Owner's Nam, Shethe San Joaquin Shell Oil Com an p,0 $ox City Stockton Lot Contractor S Address Concord ectrum Drill ,Contractor 4023 Size n CA 9 45 PM—_ TYPE OF WELL/P Adtlress2825 E M —= rtle ( Phone (415) 451_279 PUMP INSTA W WELL--0- I ❑ Stock bn "� 9 DISTANCE CATION ❑ WELL REPL L,cense No. 12268 TO NEAREST; SEPTIC TAN AGEMENT ❑ DEST Phone465-87 12 K � SEWER LINES SYSTEM REPAIR ❑ RU N Ix FOUNDATION OTH q� INTENDEDUSE �� AGRICULTURE EL DISPOSAL FLD. O Industrial TYPE OF PROBLEM ggEq WELL OTHER WELL PROP. LINE ❑ Open Bottom ❑ Man–eCa CONSTRUCTION SPECIFICATIONS PITS/SUMPS _ ❑ Domestic/Private 10 f"1 Public Gravel Pack Dia. of Well ❑ Tracy Excavation ❑ Other fl Delta TYPe of Casing ppC 1 11 litigation �— Dta. of Well Casing 4" r �..Approx. Depth I I Depth of Grout Seal 5— Specifications Repair Work pone L T Eastern Surface Se �— 7 Type of pump al Installed by Trace Type of Grout �e_ment/$en[ Hite We�Oestruction ® WeIlDiametPl H.P. Environmental (4) Sealing Material Ito State Work Done_ Depth_— Filler Material (Below 60') _ TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 1 INo Installation will serve: Residence_ septic system Permitted if Corrnercial_— Other—_ available within m fermi Public sewer is Number of living unix: Numoer of bedrooms Character of soil to a depth of 3 feeL- SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments Distance to nearer: Wall Method of Disposal sposal Property Line LEACHING UNE ❑ No. & Length of kes —� FILTER BED ❑ Distance to nearal: Total length/size Wall— Foundation SEEPAGE PITS � �— Property Line SUMPS I I Depth _—Size Ll Distance to neaopenY Line rest: Weg Number DISPOSAL PONDS ❑ Foundation I hereby certify that 1 have prepared this application and that the work will be done in accor ithr San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health D,'ktrict. Home owner or licensed agent's signature certifies the fallowing: "I certi employ any person in such manner as to hecome subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the followin fY that in the performance of the work for which this permit is issuedI shall not , tion laws of California."1 Cemfy that in the peAormance of the work for which this permit is issued, I shall q employ Per The applicant ust call for all re wired ins coons. Com late drawing P sons subject to workman's compensa- Pe Signed P 0 on reverse side. l/ Aarry Marcu_Title: Project Geologist FODate: August 14, 1989 Application Accepted by ARTMENT USE ONLY Pit or Grout Inspection by / Date �--� Area—_ Additional Comments: ate Final Inspection by :1 Silt 466-6781 I] L11 --------------� Date �� 0 Mameca fl23.1104 , mal%%Nas w E.Huaml\Av,.,P.O.Box 20x9,Stk.,CA M201 CK RECE\VED RY OA�E PEPMtT NO. PMO�N`AEM�lIEO CPSN