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i APPLICATION SAA✓.JOAQUI.N COUNTY PUBLIC REAL'i4/SERVICEf � ENVIIONMENTAL HEALTH DIVISION f 445 N SAN JOAQUIN, PHONE (209)468-3420tJ P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JUL. -1 (; 1993 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install the XIFRh4Vk36Wj@E8bed. Thi, application is made in compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 6633 Pacific Ave. — _ Cit. Stockton Lot. size/AcreagcGas Station Owner's Name Chevron USA Address PO Box 5004 San Ramon CA 510Phone 0-842-8695 .—Soils Exploration nd, ,.,,PO Box 5993, Vacavi111'_F•CAr4. C-57 707- 74 -2?i? _ V-FLL Ftt ;ZF'-A F'. ; . rF5Tr1 4'Ti,1V Otit of Service well Il PUMP INSTALLATION U SYSTEM REPAIR L) 01HER L? Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES NA DISPOSAL FLO. NA _. PROP LINE-5 FOUNDATION NA AGRICULTURE WELL OTHER WELL PITS/SUMPS IA_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Rl IndubuialMONITOR ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 19 Dia. of Well Casing 1! Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSch_40 PVC Specifications I'll Public }{3{Other 11 Delta Depth of Grout Seal 2 ' thick Type of GroutBentonite owd I I titillation ]OApprox. Depth 11 Eastern Surface Seal Installed broils Exploration Services Repair Work Done 0 Type of Pump X `;to(bk1f C-n State Work Done _ Well Destruction ❑ Well Diameter 211 Sealing Material & Depth Depth 70 Filler Material b Depth Port. cement w/ 3-5% bent. pow TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I (No 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 L1 No. b Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size _ Number SUMPS 1.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "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 workmen'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 must call for all required inspections. Complete drawing on reverse side. _ S'V ' A77%f CfIF,j Signed x__l/s�Cf /�'lGtl� Title: _ �f> � (��Z o� Date: /J— FOR DEPARTMENT USE ONLY / 45r Z�, D V Application Accepted by Date ' 1---(p ' Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 1NFO AMOUNTDUE AMOUNT REMITTED CK ICASH RECEIVED BY DATE PERM17'NO. . CH 11 24 t inel wM ",V 173 . k 'Q7 -/ 1 33 FH 14 2a