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SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA R� Telephone (209) 466-6781 - PERMIT EXPIRES 1 YEAR FROM DATE ISSUED A��i 'Q®® (CO plate in Triplicate) wherein dewed. This is t n is /. permit to construct and/or ins ^` einfAyr a ions of the San quip Application is hereby made to the San Joaquin Local Health District for a pe EALT4 made in compliance with San Joaquin County Ordinance No.548 for sewage or No. 1662 for walllpumP QIT/SERVICES Local Health District. Stockton PM City Lot Size,_ 4707 Pacific Avenue , Cali ornia B vd. � Suite 650 Job Address (415) 945-7676 UNOCAL Corporation Walnut Creek, CA 94596 Phone on Address Owner's Name 511740 Phone (916)638-80 5 Sacramentoy California LicenseNo._---- Trace Environmental Address DESTRUCTION LJ WELL REPLACEMENT ❑ NEW WELL M OTHER ❑ TYPE OF WELL/PUMP:. SYSTEM REPAIR ❑ PUMP INSTALLATINA❑ SEWER LINES 45' DISPOSAL FLD. NA PROP. LINE �6_ r NA OTHER WELL 16 0' PITS/SUMPS NA DISTANCE TO NEAREST: SEPTIC TANK 40 AGRICULTURE WELL FOUNDATION !1 f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation—r n nen-Specifications Cl Industrial ❑Tracy Type of Casing rte ❑ Domestic/Private Type of Grout C.ElIIeIIt�b a-SLt.O I'I Public Other Fl Delta Depth of Grout Seal 1 1 Easter _>------ rox. Depth n Surface Seal Installed by pp I I Irrigation H P Stale Work Done — Repair Work Done ❑ Type of Pump — Well Destruction ❑ Well Diameter ' Sealing Material (top 50') Filler Material (Below 50'1 Depen--- J available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if pub is sewer 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 r SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT.❑ Foundation Property Line Distance to nearest: Well , Total length/size LEACHING LINE ❑ No. A Length of lines Property Line FILTER BED ❑ Distance to nearest: Well Foundation _ Number 1 I Depth size __— Property Line SEEPAGE PITS Foundation SUMPS ❑ Distance to nearest: Well -- DISPOSAL 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, an rules and regulations of the San Joaquin Local Health 03trict. rmit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for sons ring suich this bject workman's signature employ any person in such manner as to become subject to workman's compensation laws of Califf shall employ ape so hiring or sub-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, tion laws of California." O The applicaust c Al for II required mspe ions. C mp ete drawing on rreveerrs aside.Geologist Date: O Title: Signed X _ FOR DEPARTMENT USE ONLY Date Area._-�-- Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: O Lodi 369-3621 C3 Manteca 823-7104 ❑Tracy 635-6385 Stk., CA 95201 ❑ Stk 466-6781 vironmental Health Permit/Services ze -1601 E. Halton Ave., P.O. Bo Applicant - Return all copies to: Enx , O RECEIVED By DATE PERMIT NO. ffE! UNT DUE AMOUNT REMITTED ..EH 1124(REV.r/R5) 5�1 EH 14211