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r` MWrY APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA S Telephone 1209) 466-6781 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 woupump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 1665 Pari fir Avenue City Stockton Lot Size PM 2175 N. California Ave. , Suite 650 Owner's Name UNOCAL Corporation Address wal_mit Creek}-CA_9A5 Phone . C4_15) 945-7676 Contractor Address 9825 E. MyrtleSt. , S oLkt0* No. 512268 Phone... (209) 465—1 871 TYPE OF WELL/PUMP: NEW WELL 1g p L) WELL REPLACEMENT ❑ DESTRUCTION Il PUMP INSTALLATION ❑c-[4- 5 SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES 60 FT DISPOSAL FLD. NA PROP. LINE 10 FT FOUNDATION 15 FTAGRICULTURE WELL NA OTHER WELL 1000 'FTITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 211 ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation �� Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack Cl Tracy' Type of Casing PVC Sched_40 Specifications Monitor 1l Delta Depth of Grout Seal 17 FT Type of Grout neat Cement I'1 Public [Other Monitor - I I Irrigation PzApprox. Depth I 1 Eastern Surface Seal Installed by - Repair Work Done 0 Type of Pump N.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material atop 501 Depth Filler Material {Below 50') - - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo 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 f SEEPAGE PITS I I Depth Size Number i 115�, SUMPS Ll 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 1 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, l shall 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." Theapplican must call for all required inspections. Complete drawing on reverse side. Signed X Barry Marc>itme. Project Geologist _ Date: 11/21/88 Fp i P� T USE ONLY C "~`="/ Area Application Accepted by __ Date F Pit or Grout Inspection by D6;o Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED I3Y DATE PERMIT'NO. kNFO A H _ • EFS 13-24 IREV.t/A 5I '� _` �Eli 14-28 ��C%c