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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE i ON AVE„ STOCKTON, Telephone (209) 466-6781 .. D PERMIT EXPIRES T YEAR; FROM DATE IS p � (Complete in Triplicate) ' Application is heiaby 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 we Local Health District. lllpump and the Rules and Regulations of the San Joaquin Job Address 2402 North Pacific Avenue Stockton City Lot Size 50X100 PM Owner's Name California Fuels P.O. Box 1207 Consul to t Address 95201 Phone (209) 466-5921 taai Q er&D<a>ne Address 121 No. Fir St. , Suite +crn9e-We- Phone 805)653-555 TYPE.OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ PUMP INSTALLATION O OESTRUC710N ❑ DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER & Soil Vapor Survey SEWER LINES � DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE• TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation — IX Domestic/Private ❑ Gravel Pack - Dia. of Well Casing ❑ Tracy Type of Casing — 11 Public R1 Other f-1 Delta 12_0 Specifications Depth of Grout Seal Type of Grout VO1Cla (�I I I Irrigation `Approx. Depth I Eastern -- '�—�--- V � Surface Seal Installed by Repair Work Done ❑ Type of Pump M.P. _ Well Destruction ❑ Well Diameter State Work Done n. — Sealing Material {top 50'i Depth 12 feet Filler Material (Below So'I lay bentonite N TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADOITION I I DESTRUCTION I I INo septic system permitted if public sewer is I Install a series of temporary Soil Vapor probes Installation will serve: Residence_,_• Commercial, Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANKWater table depth ❑ Type/Mfg _,, No. Compartments PKG. TREATMENT PLT.❑ Capacity. Distance to nearest: Well Method of Disposal Foundation Property Line n LEACHING LINE ❑ No_ & Length of lines t` FILTER BEDTotal length/siz ❑ Die Imo,J stance to nearest: Well Foundation1 Property Line i SEEPAGE PITS i I Depth Size -- Number SUMPS ' ❑ Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line i 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 rules and regulations of the San Joaquin Local Health D3trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance.of the work for which this not employ any person in such manner as to become subject to workman's compensation.laws of Cace ofia."Contractor's hiring o�sub-contracrrnit is unglsignatu e 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 call for all required inspections. Complete drawing on reverse side. Signed x Staal Gardner Dunne, Inc. 4 G / , Title: Date: FO D Q USE ONLY Application Accepted by Date ell d •�, Pit or Grout Inspection by •�� Date�^ Final Inspection b Additional Comments; Date •' ❑ Stk 466-Ml O Lodi 369-3621 ❑ Manteca 823-7104 O Tracy g35-63a5 Applicant- Return all copies to: Environmental Health Permit/Services 1601"E, Hazelton Ave,, P;O. Box 2009, Stk., CA 95201 FF AMOUNT DUE S /3 0/ INFO AMOUNT REMITTED CX5H RECEIVE] BY DATE PERMITNO.13-14(NEV.1,, FH 5146 �.