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T - ` APPLICATION FOR PERMIT aI SAN JOAQUIN LOCAL HEALTH DISTRICT a 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t 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. I 3 Job Address 22888 S. Kasson Road city Tracy Lot Size PM Owner's Name Chevron U.S.A. Address 2410 Camino RamonPhone(415151 - 9546 Contractor Krazan & Associ ates Address 3860 N. Wi ner FresnO License No. Phone 291-7337 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION.❑ SYSTEM REPAIR ❑ OTHER & soil bori ngs DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 80 ft. FOUNDATION AGRICULTURE WELL >500 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications F] Public Cl Other I F1 Delta Depth of Grout Seal Type of Grout i 1 Irrigation Approxi Depth I 1 Eastern Surface Seal Installed by - Repair Work Work Done Ll Type of Pump H P. State Work Done Well Destruction 1:1 Well Diameter Sealing Material (top 501 Depth Filler Material l$elow 50'1 — TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION l 1 INo septic system permitted if public sewer is f available within 200 feet.) Installation will serve: Residence Commercial Other OQ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:# Water table-tfg h. ! SEPTIC TANK C3Type/Mfg Capacity No PKG. TREATMENT PLT. ElMethod d � posal Distance to nearest. Well Foundation Property Line MAY i i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation. Property Line j {EISA! HEAJH i 1 � l�� SEEPAGE PITS i I Depth j Size Number SUMPS L1 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 Joaquiri Local Health Di§trict. 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 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 ap ust call fora fired inspections. Complete drawing on reverse side. i signed x T;t)e: Geotechnical Engineer Date: R D RTMENT USE ONLY Application Accepted by Date Area E Pit or Grout Inspection by Date Final Inspection b G Date e, ` r Additional Comments: 4 iyr��✓`� � � �� ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant Permit /Services all copies-to:'[environmental Health P Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 - e / FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-244REV.t/A5) $35-00 J. EH 1428 _