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APPLICATION FOR PERMIT PAYMENT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA SEP 2 8 1987 Telephone (209) 466-6781 { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH {Complete'in Triplicate) PERMIT/SERVICES 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. Job Address 3505 Navy Drive Stockton, CA City Lot Size PM Owner'slVame.Mobil Oil Co.r'poratiOlAdclmss P.O. BOX 127 RiChmond, QAPhone4J5-84q-7n67I San Jose EX Ioration GeoseryAress . i Contractor p ress 1175 COOlidqe -Ave. License No, Phon —6 8 2 TYPE OF WELL/PUMP:,_ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION 0 —,SYSTEM REPAIR ElOTHER kk boring DISTANCE TO NEAREST:"SEPTIC TANK >100 ' SEWS"L NES < 50 r DISPOSAL FLD..,*.l 0 0 ' PROP. LINEySO ' FOUNDATIONS 50 ' AGRICULTURE WELL 2 100 'OTHER WELL 7100 ' PITS/SUMPS?100 + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation NA Dia. of Well Casing NA XCR Domestic/Private »❑ Gravel Pack- ❑ Tracy Type of Casing._ NA _ Specifications T M Public Japthor l Delta Depth of Grout Seal NA Type of Grout — I 1 Irrigation 1-.a_!.Approx.'0epth I I Eastern Surface Seal Installed by NA _ peat cPmPnt-. _ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Weli Destruction Ll Well Diametel Sealing Material (top 50') n e a t C,P_m Pn t, entire ba r i n Q Depth +++***�� Filler Material {Below 50') TYPE. OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADDITION Ll DESTRUCTION I I (No septic system permitted if public sewer is `� available within 200 feet.) Installation will serve: Residence ---?AT-Commercial_ Other Number of living units: Number of bedrooms a Character-of soil to a depth of 3 feet:*' Water table depth k-S1 SEPTIC TANK - ❑ "Type/Mfg'4 Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ ( Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines. Total length/size 7 FILTER BED ❑ Distance to nearest: Well Foundation Property Line +4 SEEPAGE PITS I 1 Depth I Size Number SUMPS Ll Distance to nearest: Well Foundation. 9 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. �4;'! 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 hecome subject to-workman's compensation laws of Cefifcrnia." Contractor's hiring or sub-contracting signature certifies the following: "1 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 oftitalifdrnia." +' The applicaitT,musUcall for all required'in'spections. Complete drawing on reverse side. ..Signed x _ Title: _c}e_a-1 o g i s t Date: Q-24-2 7 { - Kaprealian Engi Bring IR 6DEPARTMENT USE ONLY •i ,Tf P. O. Box 3 'Benicia A 94510 fig '` Application Accepted by Data GC —11f' Area Ozt e , Pit or Grout Inspection by UY data �2 O Final Inspection by Date z I --7 Additignal Comments: A ..Y �o �/4 e1� 171 Stk'f 466-6781 ElLodi .•369-36211 ElMantaca 823-7104 ❑ Tracy 635-6385 .:",,Appjican Return all• Dere toi n ronmental Health Per itlServices 1601 E. Haz tone Box 2nq�' ik., CA 9 1 } x* .INFOf a}AMOUNT DUE` AMOUNT REMITTED CASK RECEIVED=BV.� DATE PERMIT'NO. +,;�+ EH 13 24.1REV�i/H 5f te' ;•� 4 �-' (/[J �/ - ��:- .c, ';cam