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kl�4 APPLICATION FOR PERMIT SAN JOAQUIN L6LrREALTH DISTRIC16 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-Ml 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 Ryles and Regulations of the San Joaquin Local Health District. Job Address 3515 Navy Dr. Rough & Ready Island CityStockton Lot Size PM .- Owner's Name Shell Oil Co. Address Same Phones 466-6941 Contractor Groundwater TechnoloWdress50/+7 Clayton Rd. ,Concord License NDC-57 4'43[t3 Phone(415)671-23 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER FS [�'10nitOrl ng 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l()=i nrhpcnrheS Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of Casing RIC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal 5 fppf- Type of Grou lte ul-Ii igatie Water Mon-30APProx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nailabple with tem emitted R public sewer is (jl (n 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 PLT. ❑ Method of Disposal n Distance to nearest: Well Foundation Property Line �+Y4( LEACHING LINE ❑ No. & Length of lines Total length/size ✓l FILTER BED ❑ Distance to nearest: Well Foundation Property Une O SEEPAGE PITS ❑ Depth Size Number l 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."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." The applicant must call for all required inspections. mplate drawing on reverse side. Signed Title: ti4 i 5' i Date: FOR DEPARTMENT USE ONLY — 17 Application Accepted by Date res , Pit or Grout Inspection by Date Final Inspection by Date D' Additional Comment . 35 r t 1 mi titatirn fee wLli be trilled Co. fr> mvfiti--- it -- tine after 1st field 'f Stk 4668781 ❑ Lodi 3693621 ❑ Manteca 823-7104 ❑ Tracy 836-8385 Applicant-_Return all copies to: Environmental Health Permh/Service; 1801 E. -Won Ave., P.O. Box 2009. Stk., D • c. 1 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE IT INFO a EH 13-24(REV.I/eel F$ 43,03 o0 34 C-9117- EH I4Z