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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT (T � f 1601 E. HAZELTON AVE., STOCKTON, CA t, ,.•,,. �4„�,... Telephone (209) 466-6781 ! 1 PERMIT EXPIRES 1 YEAR FROM DAT€ SS;Qfj (Complete in Triplicatel�(;:<<,-"�yTFtr�a� 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 of No. 1862 fur well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _ 45 East HARDING Wy. City StOCktOn Lot Size PM Owners Name Chevron U.S.A. Inc. Address 2410 Camino Ramon,San Ramon CA Phone X51842-9527 V458-3-0804- Contractor 4583-0804Contractor SDeCtrW1 EXDloration Address2R25 F Myrt-1 P St_St-nr] .Ld4�,ense No.512268 Phone(209)469-8712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER Chi Monitoring DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation l0&6 inrh Dia. of Well Casing P9 Domestic/Private N Gravel Pack [.l Tracy Type of CasingPVC—SCh 40 Specifications I'I Public Il Other I I Delta Depth of Grout Seal 20 feet Type of Grout neat Cement t I Irrigation ___.Approx. Depth I t Eastern Surface Seal Installed by tremle & Di1mD _ Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction 11 Well Diameter 4 inch Sealing Material (top 501 Depth 45 feet Filler Material IBelow 50.) . LonestarA /12 sand TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (Noseptic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other i 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 P LEACHING LINE. ❑ No. & Length of lines Total length/size FILTER.BED Ll Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth ----.Size ____ ___ Number SUMPS 11 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 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 s k p r s bj6Ft;tq qrk arr6c, .- �1 "V,14+ Pe?sAl1 4!..,_.. .."E. ,..., .r , °'lpe"�1:,I tion laws of California." r, The applicant mu call for all required y spections. Complete drawing on reverse side. -- 1 Signed X ` � /Z �1�4� Title: Date. f i CFOR DEPARTMENT USE ONLY Application Accepted by _ _ - Date —-2 - Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FE INFO AMOUNT DUE AMOUNT REMITTED CASII RECEIVED 9Y DATE PERMIT NO. . EH 13.24 IREV.1r8b)