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Note: Application for 12 Njonitoring Wells I s APPLICATION FOR PERMIT W SAN.JOAQUIN LOCALHEALTH DISTRICT 1601 E. HAZELTON tlAVE., STOCKTON, CA Telephone (209) 466-6781 _r PERMIT EXPIRES 1 YEAR FROM DATE-ISSUED' 1 (Complete i6 Triplicate) r Y „ , _ _ , w � � �^ lication is s - Application is hereby made to the San Joaquin Local Health District for a permit to construct annum install the work herein described of the app 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. �1 n. a, Job Address 3515 Na Dr. Roti h & ReadyIsland C;ty Stockton Lat Sae n1':.} PM E. _ r1 :i E. D,j . W Phone 466-6941 . . 0 ` wner's Name Shell Oil Co.. . i Address- Sallie Contractor GrdUTldWater `1"ecrlT101r3 dress5047 Clayton RC1.. Concord License NoC-574�33—Phone�415}b�1-23 7 TYPE OF WELLIPUMP: TION 13 NEW WELL ❑ WELL REPLACEMENT ❑ DESTR UC Monitoring PUMP INSTALLATION ❑ SYSTEM REPAIR Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSI5UMP5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing f D Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation 1 — Specifications t' Type of Casing - 0 Domestic/Private ❑ Gravel Pack ❑ Tracy YP Type of Grou 1Le ❑ Public ❑ Other tr ❑ Delta Depth of Grout Seal a�_IfFigmiw+Water jbn_3Ogpprox:Depth ❑ Eastern f Surface Seal Installed by Repair Work Done ❑ Type of Pum p H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material {top 501 D11 epth Filler Material (Below 50'} TYPE OF SEPTIC WORK: N11 EW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ availabYelwith ne200 feetitted if public sewer is r Installation will serve: Residence:r Commercial— Other m Number of living units: Nuiliber of bedrooms Water table depth Character of soil to a depth of 3 feet): No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity # Method of Disposal PKG. TREATMENT PLT:F1Pro Property Line Distance to nearest: Well Foundation P Y f}�L Total length/size LEACHING LINE ❑ No. & Length of lines _ Property Line FILTER BED ❑ Distance to nearest: Well Foundation D Number SEEPAGE PITS (IDepth l.,- Size r 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 Joaquln 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, l 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 call for all required mplate drawing on reverse side. Title: Date: - Signed t FOR DEPARTMENT USE ONLY �� V7 f C(II.Lv�'i Date' rea Application Accepted by Pit or Grout Inspection by Date ` Final Inspection by - Date lst Additional comment . 35 r �i cay:; Ant M fee _"'� �. Far re afi eld ii Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 F Applicant_Return all copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 s' -"7' FEEEAUNT DUE AMOUNT REMITTED _ RECEIVED BY DATE PERMIT N0. N INFO +EH 13-24(REV. a 5) .OQ EH 1426 14 -