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APPLICATION FOR PERMIT L SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR 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. clOgW. Fk.a.,r�r LK Job Address Lower Sacramento Rd. & Harmer Lane city Stockton Lot Size pM Owner's Name EXxon Cottlpany, U.S.A. Address 16945 N. Chase/Houston Texas Phone (713)874-5236 Contractor Groundwater Technolo»ydreas 5047 Clayton Rd./Concorgicense Nd434343 Phone)671-2387 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q{Monitoring Wells DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ti $1) DISPOSAL FLD. PROP. LINE72C1 FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 3 0 1 nrh Dia. of Well Casing ❑ Domestic/Private KI Gravel Pack ❑ Tracy Type of Casing M Specifications ❑ Public ❑.rz003ther N Delta Depth of Grout Seal ?0 ft- Type of Grout Ce111ent Bent i to ❑ Irrigation '<LApprox. Depth ❑ Eastern Surface Seal Installed by Groundwater Technology Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction C] Well Diameter Sealing Material (top 50'1 X 1 Oring We11 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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 will 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 linea Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, aAd 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. Complete drawing on reverse side. Signed X Title: Date: FO DPA NT US ONLY i Application Accepted b Date ��g—'$� Area Pit or Grout Inspe ton Date Final Inspection by Date r � Additional Comments: p YL . jT�z iA�5 ❑ S[k 466-6781 ❑ Lodi 389-36219-3621 ❑ Manteca 823-71 a `04—❑ Tracy 835.8385 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 RECEIVED BY INFO K RECEIVE DATE QPrERMIT NO. ♦FH 13281PFV.1/X51 gS•0o EH 1.-M CSO J W;II bL bi l)�L ~ unx pdJ;d:u tq ( soak H