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SAN -QUIP -'OUNTY PUBLIC UEALTH __AVICES ENVIRONMENTAL dEALTH DIVISION 445 N SAN .IOAQUIN, PHONE (209)468--'420 P 0 BOX 2009 , 3TOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete _n Triplicate) Application 1s hereby made to San Joaquin County for a per--t .o construct and/or !ratan the vork herein described. This application is made in compliance vlth San Joaquin County Grd!nance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. JobAddress 413 Mt. Diablo Ave. (Old Valley, Mile Tracy Zlt 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 Phone(510) 842-6855 C57658786 Contractor V & W Dr i 11 i ng Address P.O. Box 51 , Rio V i sta License No. Phone(707)374-281.5 TYPE OF WELL/PUMP: NEW WELL .VELL REPLACEMENT 7 DESTRUCTION Out of Service Well G PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well i 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 "1 Industrial C Open Bottom a Manteca Dia. of Well Excavation 8 1 n es Dia. of Well Casing 2 i n hes iX Domestic/Private t Gravel Pack X) Tracy Tvps of Casing_ SCh 40 PVC Specifications i'1 Public F1 Other it Delta Depth of Grout Seal r20 P«' Type of Grout cement/bent nl t I i Irrigation _Approx. Depth 1 I Eastern Surface Soul Installed by V & W drilling Repair Work Done Ll Type of Pump H P. __ State Work Done CA Well Destruction ❑ Well Diameter 2 inch wing Material i Depth CPMPnt/hPntnnitP grout Depth —EP,tC:t_ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDIT!ON DESTRUCTION I i INo septic system permitted it pudic sewer ms 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 ❑ Type/Mfg Capacity No. Compartments ,PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE �7 No. & Length of lines 9 Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Property Line 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 the work wiii be done in accordance witn 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: "1 certity 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 taws of California." Contractor's hiring or sun-contracting signature certifies the following: "I certity that in the performance of the work for winch this permit is issued, I shall employ persons subject to workman's comoensa- :ion laws of California." The applicant must call for ali required inspections. Complete drawing on reverse side. cc�� Signed X Title: �OG(Sf Date: a�� i (�s�/ FOR DEPARTMENT USE ONLY Application Accepted Dy v 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 O Box 2009, Stkn, CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Page 13A • EM 13•24 t11Ev.ti�si EH 11.2e