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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE-`TON AVE., STOCKTON, CA 3 wells Telephone (209) 466-6781 RW1, MW2, MWS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) all the work Application nt1complliance with San Joaquin County 0 dinnance No.549 Health District lo sewage o permit No. 1862 to,we I/dpump atnd the Rules and herein Regulations of This San Joaquin Local Health District. Stockton Lot Size PM Job Address 5606 Pacific Avenue City owners Name Unocal Corporation Address P.O. Box 5155 , San Ramon, CA _ Phone (510)277-2303 WK� 13'ry�` 33� -, gyp/ PhoneQ13� 3D0 CoAtt tor 4�D Address R ^ LicenseNo. TYPE OF UMP NEW WELL 0 WELLLJ $i REPLACEMENT DESTRUCTION [� TYPE O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C3 NA SEWER LINES 501 DISPOSAL FLD. NA POOP. LINE^'10 .� DISTANCE TO NEAREST: SEPTIC TANK 2- �_ NA OTHER WELL 40' PITS/SUMPS NA. ` FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casing NA Da. of Well Excavation C, Industrial O Open Bottom 0 Manteca NA Specifications O Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Fl Dena Depth of Grout Seal NA Type of Grout NA _ � I'i Public n Other NA - C I I kojihon �70r Approx. Depth I I Eastern Surface Seal Installed by Repair Work Oone ❑ Type of Pump NA H.P. NA State Work Done_NA 1 4n 2@2 11 Searin Material (1,0v 501 cement 3) Well Destruction ® Well Diameter 9 J Depth,70' ' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR)ADDITION I I DESTRUCTION 11 %Nosbplelwithisystem rented if public sewer isava \' Installs on will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Water table depth Character of sod to a depth of 3 feet: No. Compartments SEPTIC TANK [IType/Mfg Capacity MetlltZd PKG. TREATMENT PLT. ❑ � �FXVft ' Distance to nearest: well foundation Property Li RECE(Q'ED Total length/size } 199 LEACHING LINE ❑ No. 6 Length of lines Pro One FILTER BED NA ❑ Distance to nearest: Wen Foundation Property N ,O-,-QUIN., NTY ALlu^�._� nr,Gs Size _ Number PJoU K� 'te H c11v SEEPAGE PITS 11 Depth SUMPS NA L1 Distance to nearest: Wen Foundation r�Pe DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accords^ce with San Joaquin county ordinances,state laws, and rules and regulations o1 the San Joaquin Local Health 03vict. Home owner or licensed agent's signature certifies to following: ''I certify that in the performance of the work for which this permit is issued, I Shan not employ any person in such manner as to become subject to workman's compensation lows of California.-Contractor's hiring or sub-contracting signature certifies the following:111 certify that in the performance of the work for which this permit a issued.I shall employ persons subject to workman's compensa- tion laws of California." The applicant must con for all required inspections. Complete drawing on revena tide- Z Z Signed X _---- / y2. R&& _ -KEI Title: Staff Engineer Date: Kaprealian Engineering, In ' FOR DEPARTMENT USE ONLY q P.O. Box 996, Benicia4 10 �A Date Z¢ ( � Area3� Application Accepted by Pit or Grout Inspection by Date - �GL-Final Inspection by Data 6 Z Additional Comments: 0 Stk 466-6181 O Lodi 369.3621 ❑ Mantes 823-1104 0 Tracy 835-M Applicant - Return on copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 FEE CK i RECENED BY DATE MPERMII*NO.INFO AMOUNT OUE AMOUNT REMITTED CASN EH 1124 Iarv.lr+]1 /�D 6v 92� 2 t.t..n