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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE„ STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made toi the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San'ifoaquin County Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin made in compliance with San'i,,oaquin County Ordinance No.549 for sewaLocal Health District. Job Address 909 WEST! HAMMED LANE City STOCETLON Lot Size PM I ' Illi Owner's Name C/o EXXON COMPANY USA Address 1 Phon713 656 7. e p Houston TX 77002 ' ContractorKvilha�Well Drillit dress COnCord. CA License No.C:-57 4A919(phone4l 5 685 66 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ �C PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 3 Mc ;//" wd(s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L INTENDED USE :TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation_i fl� ' Dia. of Well Casing rr I Domestic/Private 26Gravel Pack ❑ Tracy Type of Casing PVC Specifications SCh 40 ['l Public ❑ Other f-1 Delta Depth of Grout Seal 433 Type of Grout eCnt _.. i ! I Irrigationn Approx. Depth l I Eastern Surface Seal Installed by h Repair Work Done ❑ Type of Pump _ Tl� H.P. State Work Done— r Well Destruction ❑ Well Diameter 10.2,511 Sealing Material [top 501 rpmpnt Depth _ 75' Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is I( available within 200 feet.I Installation will serve: Residence_ Commercial_ Other Number of living units: 11 Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑I Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. I-]' Method of Disposal L II Distance to nearest: Well Foundation Property Line t j LEACHING LINE CII No. & Length of lines - Total length/size It FILTER BED ❑ Distance to nearest: Well Foundation Property Line ab I I SEEPAGE PITS I I Depth Size Number 1 - SUMPS ❑ Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS -01 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 Local Health District. 11 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, 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 California." II� The applicant call f uired ctions. Complete drawing on reverse side. Signed X e � Title: !' D ta: evfl44VI bnllf,zl) FOR DEPARTMENT USE ONLY Application Accepted by i / Date L� �C� Area r �J f x Pit or Grout Inspection by III Date Final Inspection by Date Additional Comments: 1 ❑ Stk 466-6781 ❑ drodi 369-3621 ❑ Manteca 123-7104 ■ Trac 835-6385 t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT NO. � I + EH 13-24 1 REV.1/A 5Y EH 14-2a y �I