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SAN QUIN :CUNT? ?UBLIC UEALTH .VICES ENVIRONMENTAL !EALTH DIVISION 445 N SAN .JOAQUIN , ?HONE (209)468-3420 P 0 BOX 2009 , -TOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iCompiete :n Triplicate/ Application Is hereby made to San Joaquin County for a per--t -o construct and/or inatal.l the work Cerein aescribed. s application is made in coatpllance with San Joaquin County :rdinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 413 Mt. Diablo Ave. (Old Valley, Mile Tracy 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 Phons(5 10) 842-6855 C57658786 Contractor V & W Drilling Address P.0. Box 51 , Rio Vista License No. Phone(707)374-2815 TYPE OF WELL/PUMP- NEW WELL .VELL REPLACEMENT DESTRUCTION a Out of Service Well C: PUMP INSTALLATION C SYSTEM REPAIR C OTHER C Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 Industrial C Open Bottom C Manteca Dia. of Well Excavation 8 1 nC eS Dia. of Well Casing 2 1 nc hest ;x Domestic/Private t Gravel Pack It Tracy Tape of Casing_ SCh 40 PVC Specifications i'1 Public !-1 Other it Delta Depth of Grout Seal 20 4< i ImUation _Approx. Depth I I Eastern Surface Soul Installed by _V & W drill i nq Repair Work Done u Type of Pump ti P. __ State Work Done CA Well Destruction C Well Diameter 2 inch Sealing Material i Depth r Pin Pn t/ha n t n n i t P 9 rnu t Depth ifn V-t :t Filler Katerial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDIT!ny DESTRUCTION I - INC sepnc system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Cther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments .PKG. TREATMENT PLT, C Method of Disposal Distance to nearest: Well =oundation Property Line j I LEACHING LINE No. 8 Length of lines Total length/size FILTER BED J Distance to nearest: Well Fcundation Property Line i SEEPAGE PITS 11 Depth Size Number SUMPS L! Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I have prepared this application and that Ins work wui be Cone 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 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 worxman s compensation laws of California. Contractor's miring or suo-contracting signature certifies the following: "I certify that in the perform nce of the work for which this permit is issued. I snail employ persons subject to workman s compensa- tion laws of California." The applicant must tail for all required in ns. C plate arawing on reverse side. Signed X Title: 0(fO log f S f Date: 8/29-F 9-- FORD PARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by 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 CK CASH RECEIVED BY DATE PERMIT NO. Page 131 EH 13-24 tItEV.i r h si I EH t4Qa