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• ' (w 7 • f APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT j 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE I4�;UED (Complete in Triplicate) - Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TNs 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. 3505 Navy Drive Stockton Job Address _ City Lot Size PM Owner'sNameMobil Oil Corp. Address Box 127 Richmond CA Phone4l5-849-7067 ContractorExplorat ion Geoser/yd�r� 1175 Coolidge San Jt)&�lse N0484288 Phone408-280-68 2 TYPE OF WELL/PUMP: NEW WELLX-1 —I WELL REPLACEMENT (_l DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR [] OTHER ❑ C/U DISTANCE A NEAREST_ SEPTIC TANK >I 00 r SEWER LINES >10 0 r DISPOSAL FLO.>100 'PROP. LINE 1150 r (� FOUNDATION7 1 OO r AGRICULTURE WELL ��r OTHER WELL�rPITS/SUMPS 0 r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [.I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing 2 n I)t Domestic/Private k.] Gravel Pack 1-1 Tracy Type of Casing S c h e d u l e 4 0 P V Q3pecifications F1 Public ( 1 Other I 1 Delta Depth of Grout Seal N4 r Type of Grout concrete I I Irrigation ___ Approx. Depth D4 Eastern Surface Seal Installed by drilling contractor Repair Work Done [] Type of Pump - NA H.P. NA State Work Done —NA Well Destruction I 1 Well Diameter _ 211 Sealing Material (top 501 concrete Depth 201 Filler Material (Below 501 NA _ (� TYPE OF SEPTIC WORK: NEW INSTALLATION I I 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 [-1 Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. L) Method of Disposal Distance to nearest: Well Foundation ___ Property Line LEACHING LINE [ 1 No. & Length of lines Total length/size FILTER BED I I Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size .. Number - SUMPS I I Distance to nearest: Well Foundation Property Line DISPOSAL- PONDS I I 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." The applicant m call for all required inspections. Complete drawing on reverse side. Signe( x -- — Tide: geologist Date: 7/24/87 Key/o"act l�'at t-1.yI' f FOR DEPARTMENT US&-QNLY Application Accepted by Date �✓Q 4 Area 071 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Silk 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 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. . EH 13-211REV r,H5r ) \ ♦L -\ � �, L i EH It-2e GVVI�� 11 "L