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0 APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 01?32A 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sm Joaquin County 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 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3515 Navy Drive City Stockton Lot Size/Acreage approx, 6 ar, site (209)4666941 Owner's Name Shell Oil Company Address 511 N Br Anaheim CaPxhone Wc$+ F�azwer`" OrIAthy Cote. 3233 Fl+zyerald, Rx✓c�iocdfddv� G57-sC 6 Pon b) 63��z76 TC Contractor Address 24A6'-R ase Na.7c�l-l�J��L1V TYPE OF WELL/PUMP: NEW WELL X1 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well KK DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE approximate FOUNDATION 80 ft• AGRICULTURE WELL OTHER WELL._ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS DSC - ❑ Industrial ❑ Opan Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing 4 in CI Domestic/Private IN Gravel Pack ❑ Tracy Type of Casing PVC Specifications 1'I Public ❑ Other n Delta Depth of Grout Seal app - 8 ft. Type of Grout cement-bentO I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump - H.P. StateWork Done Well Destruction ❑ Well Diameter 4 1n' Sealing Material & Depth Cement-bentOnite gpprox. 0t. Depth 30 ft. Piller Material & Depth clean fine sand approx. 8-30ft. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 taws, and rules and regulations of the San Joaquin County Homo 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 snail 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." The applicant must c for all r qutred inspections. Complete drawing on reverse side. Signed x Title: Senior Hydrogeologist Date: 5-09-1991 - F OEPA T T USE ONLY Application Accepted by Oate 7 :10 ' Y/ Area 3 Pit or Grout Inspection by Date Final Inspection by ` Date Additional Comments: S2G. M'11 Cf01M �f Of'ScrNt� Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services ' 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE PERMIT NO. ��CJ o �/� EN to-2t IREV.irh sl V l'V•� �/f O 7�L/��/ ?M � EN um