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/ • APPLICATION FOR PERMIT • SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 46/5-6781 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. �� n- Job Address 3515 Roug% Read sland city Stockton Lot Sire PM Owner'sName Shell Oil Co. Address Same Phone 466-6914 Contractor Groundwater TeChAdd,ess 5047 Clayton Rd Conegga Na 434343 Ph.,,,, 671-2387 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O PUMP INSTALLATION O SYSTEM REPAIR O OTHER RI monitoring wells DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial O Open Bottom O Manteca Dia. of Well Excavation n• Dia. of Well Casing 4in. O Domestic/Private O Gravel Pack O Tracy Type of Casing PVC Specifications O Public O Other O Delta Depth of Grout Seal 5ft . Type of Grout cement&ben onl ❑ Irrigation ?Af pprox. Depth ❑ Eastern Surface Seal Installed by Groundwater Technology Repair Work Done O Type of Pump N/A H.P. I State Work Done Well Destruction O Well Diameter Sealing Material (top 501 Depth Filler Material (Below 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLL O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ 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 shall employ persons subject to workman's compensa" tion laws of California."" qqq The applicant m c f for a required specti C pI.t. d,.wing on reverse side. //Signed X nf tle: Ciwi I Fnigl ne BY Date: W��/(j ..DEPAR TUSE ONLY Application Accepted by Date �2_j�—�` Area Pit or Grout Inspec o Date Final Inspection by to Additional Comments: V4FA,, �O Stk 466-6781 O Lodi 369- 621 O Man�ta�823-7104 ,�;1.��Q' _ n 11✓/M O Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk-. CA 952 1 FEE INFO AMOUNT DUE AMOUNT REMITTED C /RECEIVED BY DATE nPERMITEH 1171(REV.t/n5)) S� 3EH 1474 •J rE��o� °racf4,�.