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1 APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, C Telephone (209) -6781 PERMIT XI 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 well/pump and the Rules and Regulations of the San Joaquin Local Health District. *Install network of landfill methane gas extraction wells within the City of Stockton Austin Road Waste Disposal Site. (See attached Location and Development Plan) . Job Address 8903 South Austin Road City Manteca Lot Size 135 Ac. PM Owner's Name City of Stockton Address City Hall' Stockton, Ca. 95202 phone 944-8339 Pacific Lighting Energy Systems N/A (213)725-1139 Contractor's Name License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER M DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES NIA DISPOSAL FLO. NIA PROP. LINE FOUNDATION AGRICULTURE WELL —25-0-L OTHER WELL N A PITS/SUMPS NIA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 411-611 Dia. of Well Casing V ❑ Domestic/Private IX Gravel Pack ❑ Tracy Type of Casing PVC Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seal None Type of Grout NIA ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by N/A Repair Work Done ❑ Type of Pump N/A H.P. NIA State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 NIA Depth—Land Fill Depth Filler Material (Below 50') NIA TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 SEEPAGE PITS ❑ Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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, I 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 C lifornia." The applic t ust call for II r quired i pections. Complete drawing on reverse side. Signed Title: Director Of Public Works Date: City of Stockton 4mFO T T USE LY Application Accepted by Date J Area j Pit or Grout Inspection t Date Final Inspection by Date Additional Comments: ❑ Stk 6781 ❑ Lodi 1 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + 13-24(REV.10/83) ,t, s _ �7 EH 14.26