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APPLICATION L � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE �� ENVIRONMENTAL HEALTH DIVISION O 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDJUL 16 1993 (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made.to San Joaquin County for a permit to construct and/or install the u9RN;J/SERVCE8bed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 6633 Pacific Ave. City Stockton Lot Size/AcreageGas Station Owner's Name Chevron USA Address PO Box 5 0 0 4, San Ramon CA Phone 51 0-8 4 2-8 6 9 5 ContractoPoi1S Exploration AddresSPO Box 5993, Vacavi1kkeQANo.0-57 Phone 707-745-2928 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES NANAFLO. NAPROP. LINE"_ FOUNDATION NA AGRICULTURE WELL OTHER WELL PITS/SUMPS U&_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS X1 IndusuialMONITOR ❑ Open Bottom ❑ Manteca Dia. of Well Excavation R Dia. of Well Casing 2t1 Cl Domestic/Private ❑ Gravel Pack O Tracy Type of CasingSch 40 PVC Specifications I'1 Public }¢kOther Cl Delta Depth of Grout Seal 2 1 thick Type of GroutBentonite lowd I I Irrigation 7QApprox. Depth 11 Eastern Surface Seat Installed byoils Exploration Services Repair Work Done 0 Type of Pump X -qt0d1?to13 State Work Done _ Well Destruction O Well Diameter 711 Sealing Material & Depth Depth 701 Filler Material & Depth Port. cement w/ 3-5% bent. pow TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line (1 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: 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: "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 workman's compensation laws of California."Contractor's hiring or subcontracting 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 requir inspections. Complete drawing on reverse side. .—/,$"CaL A-7A61 E% Signed Title: �i`��% l� f� Date: /J J�/Ly r4f� FOR DEPARTMENT USE ONLY //}/ S^ 0, . D Application Accepted by Date ' G-�Jj Area L)n111, Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: t _ 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 95201FEE .. INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. . EH 13-21 1REV.I/n 51 � EH 11-2e 89 �� l-13 � YYY T QL •` ` c� J