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!; APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES V llllll .k EN V I RONMENTAt HEALTH DIVISION PHONE (209)46$=3420 NOV 19 1992 P O BOX 2009, STOCKTONt CA 95201 - RE YEAR FROM DATE ISE117n ENVIRONMENTAL HEALTH i! (Completer in Triplicate) PERMIT/SERVICES .1I Application is hereby nAde t6'13en Joaquin County for a per&it to construct and/or install the work herein deiscribed. This application IS made in coniliance with San Jodqu ourlty ordiniftce No. 549 end 1662 and the Rules and Regulations of San Joaquin CountyPS,HS�ry Ir Job Addreail SQTr} BD OF CHRISMAN RDO , 15001 S 0 I-5 City Lot size/Acreage ii OFF RAMP owner's Name TEXACO TRADING & TRANSes 5005 BUSINESS PARK NORTH #200 Phone 805 327-0110 !X01ZSF1- ELU,U 9330T AMERICAN CONSTRUCTION & 1038 REDWOOD HWY. #.2 License No. 310599 Phon�415 381-08-:8 Conttacloi 4 Address TYPE [OF WELL/PUMP: A NEW WELLWELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Ke11 GI Monitoring Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 4O' DISTANCE TO NEAREST; SEPTIC TANK NONE -- SEINER LINES _NrL _ DISPOSAL FLD. NONEPROP. LINE FOUNDATION AGRICULTURE WELL NONOTHER WELL - PITS/S jmps NON i INTENDED USETYPE OF WELL ,PROBLEM AREA CONSTRUCTION SPECIFICATIONS r WH M C) Industrial ❑ OpenBottom ❑ Manteca Dia. of Well Excavation 9 _ Dia. of Welf Casing 2 f.l DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ DYC Specifications HCH_ 40 �> •li �[ I�LR)��€CATHODIC I Othei, Il Delta Depth of Grout Seal 130_t _ Type 6f Grout 11-SIC CEMENT I I IrriUation Approx. Depth l 1 Eastern Surface Soul Installed by Repair Work bone 0 type bf'Pump -3jf1NF. - H.P. State Work bone Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material & Depth { TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [ I DESTRUCTION l 1 (No septic system permitted if public sewer is available within 200 feet.) Installetion will serve: Residence Commercial— Other !Number of living units: Number of bedrooms _ I 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 0 No.'A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Sire Number SUMPS El 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, ani[ rules and regulations of the San Joaquin County Nome owner or licensed agent's Signature fd: I certify that In the performance e w certifies the foliowin " fof thork for which this permit is issued, I shall not ' employ any person In Such manner as to become subject to workmen's Compensation lawn of California," Conlraclor's hiring or sub-contracting signature certifies the follow' "l certify that in the performance of the work for which this permit is lisued, I shall employ persona subject to workman's compenca `a tion laws of Ceti a.,, The applies I fo 1 quire spectioris. Complete drawing on reverse side. Signed Title: PROJECT MANAGER Date: 11-17-92 S E H .-MCK. FPR D PARTMENT USE ONLY , Application Accepted by �� Date Area P , Pit( rr pection by ate 4Y Final Inspection by Date Gtout lnln / Z Additional Comments: r. Applicant - Return all copies to: San Joaquin County Public Health I� Services, Environmental Health Permit/Services .- li 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 y FEE AMOVNT'DUE AMOUNT R ITTED CK II RECEIVED 9Y ATE /I�NfFJOJ� Q Q � EH 1324{REV.r�e9i f.L//� V (s 0-0 EH 142E , irTp-