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yam' APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT at a E. STOCKTON, CA 1601 E. HAZEL i ON AVE., SMJOALQUIN.CAUNTY-PUBLTCIM )ESU one (209) 456-6781 D ��B Q $NYI�tONMBNTALI MaT.PAWS FIRES 1-YEAR FROM DATE ISSUE SPECIAL PE RMI"j' {Complete in Triplicate) F�fVIRpNM i�3A1 HEAapplication is onstru Application is hereby M to the San Joaquin Local Health District for sewage or it to 1862 for made I pump and the Rules anted Regulations of the San Joaquin made in compliance with San Joaquin County Ordinance Local Health District. . StocktonLot Size 100'-250' PM 1444 Lincoln Way City ' Job Address and 10 Universal City Plaza Texaco Refining Phone 818 5 5-2476 TeXaiInc. Address Uni ersal Cit Owner's Name n 1401 Halyard Dr. , Suite 140 X916 372_47 0 Groundwater `fief y Contractor TeChn01 __Ing. Address W2 St SaCramerit0 Ca. License C 343 .—Phone NEW WELION C5 L I WELL fiEPLACEMENT ❑ n TYPE OF WELL/PUMP: SYSTEM REPAIR OTHER ❑ PUMP INSTALLATION 1-2DISPOSAL FLD. POOP. LINE I SEWER LINES �— PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK _--� AGRICULTURE WELL OTHER WELL FOUNDATION _��-- 411 i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing f ❑ Open Bottom ElManteca Dia. of Well Excavation El Industrial 4 T e of Casing PVC Specifications Neat Cement ❑ Domestic/Private (XGravel Pack ❑ Tracy depth of Grout Seal 25' Type of Grout n Other n Delta Contractor l`1 Public Surface Seal installed by I I Irrigation 41'Approx. Depth i I Eastern State Work Done — H.P. Repair Work Done ❑ Type of Pump Bentonite and Neat Cement Well Destruction ❑ Well Diameter 1__0.5- Sealing Material (top 50'1 x-monitoring Well Depth 45 Filler Material Iselow 50'1 4 TYPE OF SEPTIC WORK: NEW INSTALLATION t.� REPAIR/ADDITION l 1 DESTRUCTION t I availablelwi within 200 feettled if public sewer is Installation will serve: Residence— Commercial Other� +� Number of living units: Number of bedrooms Water table depth S Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal Q PKG, TREATMENT ?.LT. ❑ Foundation Property Line Distance to nearest: Well Total length/size LEACHING LINE ❑- No. 8 Length of lines Property Line ❑ Distance to nearest: Well Foundation P Y FILTER BED ..I I i Size Number SEEPAGE PITS I i Depth Property Line SUMPS ❑ Distance to nearest Well Foundation - f DISPOSAL PONDS El- � 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, an rules and regulations of the San Joaquin Local Health District.g Home owner or ticl not enseuc�g manner. to become subject following: workman's rtcompensation lify that in the aws of Califorrnia."Contractor's rhiringl or sub-contracting signature employemploy any person persons subject to workman's compensa- certifies the following: "I certify thatin the performance of the work for which this permit is issued, I shall employ tion laws of California." The applicant plust all for all requir ins ctions omplete drawing on reverse si le . Title: l T l) Date: Signed X r „ ,POR D MENT USE ONLY 96Area Date V Area Application Accepted by �., -�J Final Inspection by Dat�7i�rr`� Pit or Grout Inspection by Date. � . e i`t ,- t a4enev /JA I G e°n c h Additional Comments: Q Manteca 823 7104 ❑ Tracy 835 ❑ Stk 466-6781 ❑ Lodi 369-3621 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 x l CK RECEIVED 8Y DATE PERMIT NO. f!' FEE AMOUNT DUE AMOUNT REMITTED CASH # INFO r EH 13-24(REV.1/R 5) S5 "ICU Z41#17 EH 14-2a