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D42_,�Ix 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 to 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 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. Naval Communications Station Job Address Rough and Ready Island City Stockton Lot Size PM Fyffe Ave. Owner's Name U. S. Navy Address Stockton, CA 95203-5000 Phone(209)944-0244 1901 Olympic Blvd. Suite 300 Contractor. J. H. Kleinfelder Address walnut Creek, CA 94596cense No.467252 Phone (415)938-56 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ /�/1 PUMP INSTALLATION L-1SYSTEMREPAIR 11OTHER.1516- mem /-15�e 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 V-10 Dia. of Well Casing 2" ID. ❑ Domestic/Private EXGravel Pack ❑ Tracy Type of Casing Stainless Steel Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal RE:Diagrams Type of Grout 4% Bentonit C Irrigation 15'-1Wprox. Depth ❑ Eastern Surface Seal Installed by J. H. Kleinfelder 96% PorflancJ emen Repair Work Done ❑ Type of Pump NA H.P. NA State Work Done Well Destruction ❑ Well Diameter NA Sealing Material (top 50') Depth NA Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within.200 feet.) Installation will serve: esidence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 t: 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 ❑ No. & LengjYf of lines Total length/size FILTER BED ❑ Distance o nearest: Well Foundation Property Line SEEPAGE PITS D th Size Number SUMPS [];/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 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 m s call for al� uired inspections. Complete drawing on reverse side. Signed X � Title: Hydrogeologist Date: 10-17-86 d E ONLY Application Accepted by Date /�-�� -��% Area —2'-06— Pit or Grout Inspecti n Date Final Inspection by Date Additional Comments:z� ��LLy ��°ylJ.P'G� i0� �i�i/� / SC�}z-,(�IG��L l? Qom,or "> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma ca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT NO. + EH 13-24(REV.1/a 5l7QS J� ov 1 — l� �S GC5 ^1 ^ EH 14-Zf3