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^ .r ' APPLICATION FOR PERMIT I SAN JOAQUIN LOCAL HEALTH DISTRICT G1601 E. HAZI<LTON AVE., STOCKTON, CA S 2 Telephone (209) 466-6781 1�' PERMIT EXPIRES 1 YEAR FROM D �� ATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install Ithe 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 Ryles and Regulations of the San Joaquin Local Health District.9� 9 _+( + [k Job Address Hi4 - Q �� ane s�e�N StOCtort . _qQCity Lot Size 150'x200` pM NIA Owner's Name Chevron USAP. - 95001 Address D, �; .0 04<, .San Ramon,,_Ca_,- Phone 415-842-9500 Contractor West Hazrrtat Dr19 Address3233 Fitzgerald, Cordova Ca' C57 55497 License No. 9Phone 916-638-727 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK >150, SEWER LINES 7 100' >OTHER _V Monitoring (3) FOUNDATION y.150' DISPOSAL FLDr . PROP. LINE AGRICULTURE WELL �150rOTHER WELL 7150' PITS/SUMPS/150' INTENDED USE TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS ❑ Industrial ET Open Bottom ❑ Manteca Dia. of Well Excavation 2 Dia. of Well Casing 4" ❑ Domestic/Private Chf Gravel Pack ❑ Tracy Type of Casing PVC Specifications �} ❑ Public ❑ Other ❑ Delta Depth of Grout Seal - 55' ❑ Irrigation 58-8Approx. Depth ❑ Eastern Surface Seal Installed by West HazmatpDrilling Volcla 0' Repair Work Done ❑ Type of Pump NIA H.P. N A State Work Done Well Destruction ClWell Diameter 4" Sealing Material (top 50') Volclaq MMonitoring Depth 80' Filler Material (Below 50') Volcla TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is } Installation will serve: Residence_ Commercial_ Other available within 200 feet.) y Number of living units: 'Number of bedrooms Character of soil 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 v� LEACHING LINE - ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth 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 must all required inspections. Complete drawing on reverse side. / Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area ty G IAddiPit orOE311nspection by Date Z-7- Final Inspection by Date a -I?- Additional tional Comments: f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 AMOUNT DUE AMOUNT REMITTED C RECEIVED 13Y DATE PERMIT"NO. INFO CASH + EH 13-24(REV.i/s5) ` EH 1426 raw 759 S N IL