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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR F%& DATE ISSUkP (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or inste.11 the work herein described. This application is made in compliance J. Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 11.1 Job Address 3515 Navy Drive 1 _ City Stockton Lot Size/Acreage aAArOX. 6 acres. 51.1 N. Brookhurst Owner's Name Shell Oil Company_ Address Anaheim CA Phone 209-466-9213 P.O. Box 5993 Contractor SES/Harding Lawson Address Vacaville CA License No.C-57 582692phone 707-451-921 TYPE OF WELtlPUMP: NEW-WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION o Out of Service Well 0 0i PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK; SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIOW AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS W Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation— Dia. of Well Casing Specifications r` [-.1 Domestic/Private Cl Gravel Pack. E3 Tracy Type of Casing_ (n I'1 Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout I I irrigation _-__Approx. Depth I I Eastern Surface Seal Installed by . I Repair Work pone U H.P. State Work Done Type of Pump ,. Well Destruction ❑ Well Diameter r Sealing Material i Depth Depth ! Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION t I (No septic system permitted it public sewer is f available within 200 feet.) } Installation will serve: Residence r +Commercial _ Other l r 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.O Method of Disposal Distance tonearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to;mwrest: 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 regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 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 Callfornla." ' The applicant must call for ai luited ' spa ns. Complete drawing on reverse side. Signed nom-+ Title. Senior Geologist Date: 8/10/93 Bruce L. 11Cer FOR DEPARTMENT USE ONLY ,p Application Accepted by Data Area Date Z-� �3 Final Inspection by Date { Pit or Grout Inspection by t L Additional Comments: r Applicant - Return all copies to: San Joaquin County Public Health Services j Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE if AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. � INFO p 1, p q EK 13-24(REV.I/it 5) r� EN l4>e