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SAN JOAQUIN COUNTY-PUBLIC HEALTH i ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR PERMIT SPECIAL PERM J LOCAL HEALTH DISTRICT 1 E.. HAZEHAZE:LTON AVE., STOCKTON, CA Telephone (209) 466-6781 4 wells PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MW10, Mwll , MW12, MW13 (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work he described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/Dump and the Rules and Regulations of the San Joaquin Local Health District. City Stockton Lot Size PM Job Address 5606 Pacific Avenue P.O. Box 5155 , San Ramon, CA Phone (510)277-2303 Owner's Name Unocal Corporation Address 9 Contractor �.IARD Address ��'U . 3✓(0/-"v —License N 057-J270 Phony IP7 WELL REPLACEMENT ❑ DESTRUCTION C3TYPETYPE OFA NEW WELL Sl SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION G NA PROP. LINE �LOt NA SEWER LINES SO r DISPOSAL FLD. DISTANCE TO NEAREST: SEPTIC TANK LO r AGRICULTURE WELL NA OTHER WELL i_40' PITS/SUMPS NA FOUNDATION INTENDED USE Dia. of Well Casing TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2rt G Industrial ❑ Open Bottom G Manteca Dia. of Well Excavation Type of Casing PVC, SCH 40 Specifications G Domestic/Private ❑ Gravel Pack ❑ Tracy —401 Type of Grout Approx. DeCement Public by KI monitoring _ J 4 (1 Other fl Deka Depth of Grout Seal\ Concrete pump —_BIl Depth 1 1 Eastern Surface Seal Installed NA H.P. NA State Work Done NA Repair Work Done L3 Type of Pump 11 sack cement/sand slurry Well Destruction ❑ Well Diameter t 2" Sealing Material tt 'JCY Monterey sand 113 Depth 180' Filler Material IBNewiB-L TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I 1 availabllerc system wknin 200 feel.)permitted it public sewer is NA installation will serve: Residence_ Commercial__ Other 1 Number of living units: _ Number of bedrooms R pMj "' Water to me*oe Character of soil to a depth of 3 feet: No. Cq�� F SEPTIC TANK ❑ Type/Mfg Capacity Meth f d 16rspios0l PKG. TREATMENT PLT.❑ Property Line C D L Y .. Distance to nearest: Well Foundation ce y SAN OAQUIN COUNT'i L ti Total lengtfil5t LEACHING LINE ❑ No. d Length of lines ProFFperty mne I IAL L FILTER BED NA ❑ Distance to nearest: Well Foundation SEEPAGE PITS I I Depth Size Number SUMPS NA Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 D13trict. ^CC Home owner or licensed agent's signature certifies the following: '"I certify that in the performance of the work for which is sh Wil employ any person in such manner as to become subject to workman's compensation law ,nr1l s�I�[m++�, � .�",�ysa certifies the following: "I cenify that in the performance of the work for which this permit i$issueC I �?"r" Mr` tion laws of California." SPECIAL P IT The applicant must call for all required inspections. Complete drawing on reverse side. Z, 2 /, y ,L fi Qq�, /fG —KEI Title: Staff Engineer Date: C/Signed X �7 Kaprealian Engineeri , Inc 4S 1OFpR DEPARTMENT USE ONLY P.O. Box 996, Be i C Date � Z Application Accepted by SLZ' Date Final Inspection by SZ Date Pit or Grout Inspection by Additional Comments: / fl1Y ❑ Stk 466-6781 ❑ Lodi 369.3621 G Manteca 823.1101 ❑ Tracy 835-6385 � Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA ZE! CKs RECEIVED 9Y DATE PERMITNO. UNT OUE AMOUNT REMITTED cgSH a zF Z o35Z . EM 1.N IREV.v+Si E.to ZE