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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., ST©CKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lCompiete 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 Rqles and Regulations of the San Joaquin Local Health District. 1_� A 3515 law D -r. _ Rotmh R, Rcacly TslgM :. Stockton r:_,, DRA Owner's Name Shell 'ail CO • Address Same Phone 466-6941 Contractor Groundwater Technolo dress5047 Clayton Rd. ,Concord License Nod --57 4 343 _ Phone(415)671-23E TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ DATE PERMIT' No. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER N Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE X13 , 4 �. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing EW Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Sea! 5 feet Type of Grou 50-46@868RWater Mon.-3OApprox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. _____ , _ State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 _ Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION d-' DESTRUCTION ❑ (No septic system permitted if public sewer is available within 2OG faet.l 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. ❑ Method of disposal Distance to nearest: Well Foundation Property Line 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 ❑ 7 Lte l� I hereby certify that I have prepared this application and that the work witl 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 call for all required inspections olete drawing on reverse side. Signed X Title: ?=✓� `5 Date: FOR DEPARTMENT USE ONLY -- 17 Application Accepted by Date J rea QvLLti Pit or Grout Inspection by Date Final Inspection by date_ O r Additional Comment : 35 r +qmi oa�ul> atlas fee wil be filled CO, far a±ktLcn31 titre af` eld 'XStk 468-6781 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 835-6385 D t• Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,ff 7 o I + EH 13-24 IREV. r / a 5 EH 14-25 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT' No. $ 43.W X13 , 4 �. s I C --dr- Irl W -E5 1 ss $N