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.iYYI L 1,,l 1'i(JN SAN AQUIN COUNTY PUBLIC HEALTH _ _AVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, 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 San 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 Regulstlons of San Joaquin County Public Health Services. Job Address 413 Mt. Diablo Ave. (Old Valley, Mile c,t, Tracy Lot Size/Acreage 3.04 acres Post 215 Site) 4000 Executive Parkway, Bishop Ranch No. 8 Owner's Name Chevron Pipe Line Address San Ramon, CA 94583-0959 PhonJ510) 842-6855 C57658786 Contractor V & W Dr i 11 i ng Address P.O. Box 51 , Rio Vista L cense No. Phone(707)374-2815 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ;i DESTRUCTION E'j Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E1 Industrial ❑ Open Bottom a Manteca Dia. of Well Excavation 8 1 nC eS Dia. of Well Casing 2 i n hes A Domestic/Private (K Gravel Pack t Tracy Type of Casing_ SCh 40 PVC Specifications i'1 Public 11 Other 1� Delta Depth of Grout Seal '20 F«� Type of Grout cement/bentoni to I i frnoauon _Approx. Depth I I Eastern Surface Seal Installed by V & W d r i 11 i nq Repair Work Done ❑ Type of Pump H.P. __ Stats Work Done CA Well Destruction ❑ Well Diameter 2 inch Sealing Material i Depth c Pm a n t/hP n t n n i t P grout. Depth LIQ c'� Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i i DESTRUCTION I I INo septic system permitted it public sewer Is available within 200 fest.) 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: ell Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this app ication d that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the follow ify 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 wo ompensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the wor t wh this permits issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for ali required inspections. Complete drawing on re sid q p c-- Signed X Title: Zo Date: T 1,/J FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK" RECEIVED BY DATE PERMIT'NO. EH 13-24(REV.i/n5) Page 13A EH 14.20