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LICATION FOR PERMIT • JCIAOUIN LOCAL HEALTH DISTRICT *�PERMIT 1 E. HAZELTON AVE., S -6781 N, CA Telephone (209) 466-6781 EXPIRES 1 YEAR FROM DATE ISSUED l�S"��ji►� (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct an install the work herein described 's 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 the San Joaquin Local Health District. - 25,200 Sgft City StOC(Ct�n Lot Size Job Address 4707 Paci f i C Avenue 510 277-2320 Unocal Corporation Address P•�• Box 5155, San Rartan, CA 94583 Phone owner's Name 581639 (707) 347-4300 Contractor Ia Qr111ing Address P.O. BOX 336, Rio Vista License No. Phone - -- NEW WELL � WELL REPLACEMENT ❑ DESTRUCTION ❑ TYPETYPE OFA _ SYSTEM REPAIR El DISPOSAL C3PUMP INSTALLATION 111001 201 •201 DISPOSAL FLD. N/A PROP. LINE 599--W SEWER LINES DISTANCE TO NEAREST: SEPTIC TANK N/A 0 A OTHER ' ELL Ste'- gk3D PITS/SUMPS N/A FOUNDATION cea Mp AGRICULTURE WELL2i, ffntlitcring well/4° vapor wel TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Dia. of Well Casing 2 & 4 1nC INTENDED USE ❑ Manteca Dia. of Well Excavation - ❑ Industrial ❑ Open Bottom SCh 40 PVO Specifications t ❑ Tracy Type of Casing betltOnite & C Gravel Pack 201 & 651 Type of Grout ❑ Domestic/Private ❑ Delta Depth of Grout Seal t.,d �,•illinQ CoTyany f•1 Public ❑ Other 45-5pprox. Depth l I Eastern Surface Seal Installed by I I Irrigation State Work Done — H.P. Repair Work Done ❑ Type of Pump — Sealing Material (top 50.1 Well Destruction ❑ Well Diameter Filler Material (Below 501 _ Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR%ADDavailable)within 200 within d public sewer is ITION ! DESTRUCTION I I Installation will serve: Residence Commercial_ Other Number of living units: — Number Number of bedrooms Water table depth Character of soil to a depth of 3 feet: - Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Meooasd� PKG. TREATMENT PLT.❑ Foundation Property LOOP Distance to nearest: Well Total length/size LEACHING LINE LlNo. & Length of lines Property Ina NTY FILTER BED ❑ Distance to nearest: Well Foundation SAN iJOAQUne Number PUBLI ^ iSION SEEPAGE PITS I ] Depth Size 'Prbpe y ine SUMPS LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I shall not rules and regulations of the San Joaquin Local Health following: 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, employ any person in such manner n to become subject to workman's compensation laws of California."Contractors hiring or subcontracting 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." 9 The applicant call for all equired inspections. Complete drawing °^ reverse side. L,n�n n/ Date: Title: %!!! -.-- Signed - FOR DEPARTMENT USE ONLYDate*LArea Application Accepted by 3 �7 7r Date Final Inspection by Date Pit or Grout Inspection by Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 8358385 ,�11 ❑Stk 466-6781 ❑ Lodi 369-3621 Stk., CA 95201 r Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box I r. CK C VED BY DATE PERMIT NO. ..... FEE AMOUNT DUE AMOUNT REMITTED nC�]ASS�H/� �•` INFO 444 yy//�y�}��,, Ate-, l�/i l'1 �'�� J2 ��1J ♦.EH 1324(REV.1/x5)�� "� r/ ��Vv EH 1/-29