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APPLICATION FOR PERMIT 1 _ SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 I PERMIT EXPIRES TYEAR 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. 076—,7(06 k 3505 Navy Drive Stockton r Job Address- City Lot Size PM owner's NameMobil Oil Corp. Address Dox 1.27 Richmond CA Phone415-849-7067 ContractorExploration G.eoserArdk1175 Coolidge San JQr`e�rrse NQ484288 Phone408-280-68 2 TYPE OF WELL/PUMP: NEW WELL,-,0 —I- WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE T',& NEAREST: SEPTIC TANK >100 ' SEWER LINES; >100 ' DISPOSAL FLD. >1 00 'PROP. LINE —50 r FOUNDATION --X!—.AGRICULTURE.AGRICULTURE WELL ] S0 ' OTHER WELL 50 'P1TS/SUMPS]50 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 n " L)tDomestic/Private ? Gravel Pack ❑ Tracy Type of Casing Schedule 40 PVCSpecifications ('l Public ❑ Other .� ❑ Delta Depth of Grout Seat N4Type of Grout concrete- '� drilling I I Irrigation ---Approx. (}4 E:astorn Surface Seal Installed by contractor Repair Work Done ❑ -Type of Pump NA H.P. NA State Work Done NA Well Destruction ❑ Well Diameter 2 tr Sealing Material (top 60') concrete Depth 2 0 t Filler Material (Below 50') NA TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION (.I DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial'-- Other - 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. ❑ y Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size- FILTER BED ElDistancre to nearest: Well Foundation Property Line i SEEPAGE PITS I'I Depth f Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ E 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. r' 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 F 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." t The applicant m call for all required inspections. Complete drawing on reverse side. Signed Title: geologist Date: 7/24/87 - FOR DEPART ENT US _ON LY Q , Application Accepted by Data Area { Pit or Grout Inspection by Date Final Inspection by Date v 7 Additional Comments: ❑ Stk '466-6781 .. ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 rr FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO lC.�a EH 14-24{gFV,'1/nsl L\ �Q F _\ i. �� 14 FH 26