88-2955 - Laserfiche WebLink

Home Browse Search

p APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' ' AVE. STOCKTON CA 1601 E. HAZELTON ON Telephone (209) 466-6781 , � $ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �iTAL HEALTH L-NVIFtUME., Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo'Vre MCF411d application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District, Job Address 45 East Harding Way City Stockton Lot Size PM 2 Annabel Lane, Suite 200 Owner's Name Chevron U.S.A. Inc. Address San Ramon, CA 94583 Phone (415)838-5300 2825 East Myrtle Street Contractor Spectrum Exploration Address Stockton, CA 95205 License No.512268 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 99 Monitoring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation —1nC Dia. of Well Casing 4—inch Domestic/Private RP Gravel Pack ElTracy Type of Casing Sch 40 PVC Specifications l'1 Public ❑ Other ❑ Delta Depth of Grout Seal 39 feet Type of Grout Neat Cement I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter 4—inch Sealing Material (top 50'1 Neat cement and bentonite grout Depth 62 feet Filter Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I l Mo septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of sail 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 l LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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, a rules and regulations of the San Joaquin Local Health District. 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." The applicant must cat fo it re u'ed inspections. Complete drawing on reverse fide. Signed X Title: Date: L� r FOR DEPARTMENT U E ONL r 00 Application Accepted by Date �/ Area Pit or Grout Inspection by Date Final Inspection by_ r Date Additional Comments: ❑ Stk 466-6781 Lodi 1 0 ❑ Manteca 823-7104 Trac 835- Applicant- Return all Ales to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED 3H RECEIVED BY DATE PERMIT'NO. INFO f/ + EH 13-241REV.t/H51 V0-aq EW 14-2a