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F � APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED Telephone (209) 466-6781 ;\`3V 1989 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY (Complete in Triplicate) PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH 01VIS10N 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 Rules and Regulations of the San Joaquin Local Health District. Job Address 1403 Country Club Boulevard City_Stockton Lot Size 0.918 a PM 95670-6020 Owner's Name BP Oil Company Address 2868 Prospect Park Dr. #360 Phone 916:611—f17R3 Contractor IT Corporation Address_4585 Pacheco Blvd 94553 License No. 137422 Phone$ TYPE OF WELL/PUMP: NEW WELL XX WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK +150' SEWER LINES 40' +150 FLD. +150 r PROP. LINE 40' FOUNDATION __30r AGRICULTURE WELL +15nt OTHER WELL+150! PITS/SUMPS S.0-r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS IX Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1111 Dia. of Well Casing 411 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing PVC Specifications 1'1 Public IX Other 4 Delta Depth of Grout Seal TED Type of Grout TBD I I Irrigation 4J-,Approx. Depth I I Eastern Surface Sual Installed by TRD _ Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Itop 501 Depth Filler Material (Below 501 _ TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 I DESTRUCTION I I INo 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 ❑ 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 1 I Depth Size Number SUMPS 0 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 re8ulations of the San Joaquin Local Health Di§trict. 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, 1 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 fokowing:"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 applicant st call for all uireins c ps. Complete drawing 7%4 side. Signed Title: G""" "d-� Date: FOR DEPARTME T USE JNLY Application Accepted by — r Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 O Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmentpl Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK f CASH RECEIVED 8Y DATE PERMIVNO. ♦ EM 13-24(REV.t/xst EH 14-'$