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APPLICATION FOR PERMIT t *' V SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA 's ' Telephone (209) 466-6781 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED (Complete in Triplicate) rrNVi 8141 EP4 TAL HEALTH Rrvtt7/SEPt Application is heteby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described: Thf =aplication 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. Job Address 950 11th Street•; city Trace Lot Size 10 5 1 125' PM . Owner's Name Desert Petroleum Address P.O. Box 1601 , Oxnard CA 93032 (805) 644-6784 x Phone T� 1�i�.t+-L.L O& 8403 Its ©PICC, a. I -rR.uSOft Contractor �EESM.RN GEO-�ENGTNEER ` � 4 ��1� (OS2 � address icense No. W -Phone 1 TYPE OF WELL/PUMP: (monitor NEW WELLS N three) WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLAT16N ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE; TO NEAREST: SEPTIC TANK —.SEWER LINES 25 r ± DISPOSAL FLO. PROP. LINE ,1 0 ± FOUNDATION 1 0 * AGRICULTURE WELL OTHER WELL PITS/SUMPS 10 ± INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N Industrial Monitor)❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7-7/$,!' pia. of Well Casing 2" ❑ Domestic/Private U Gravel Pack ba Tracy Type of Casing PVC Specifications I`1 Public n Other ❑ Delta Depth of Grout Seal 8, Type of Grout Neat HentOr4 e I I Irrigation 26' each- Approx. Depth I I Eastern Surface Seal Installed by Driller Repair Work Done LJ Type of Pump None H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material (top 50') Depth Filler Material (Below 50') TYPE OF SEPTIC WORK: NEW.INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewe, is available within 204 feet.) n Installation will serve: Residence Commercial— Other �f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK © Type/Mfg Capacity No: Compartments PKG. TREATMENT PLT. ❑ Method of Disposal {per Distance to nearest: Well Foundation -Property-Line LEACHING LINE 0 . No. & Length of lines Total length/size FILTER BED C Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done.in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or syb-contracting signature' certifies the following: "I certify that in the performance of the work fof which this permit is issued,1 shall employ persons subject to workman's compensa. tion laws of Californ" . The applicant m call r io Complete drawing on reverse side. Signed X Title: — bate: .4/2 /88 FOR DEPARTMENT USE ONLY App cation Accepted byL_ Dat$ r Pit or GroA ea ut Inspection by ` Dat Final Inspection by Date Y . Additional Comments: lA�. lLiS Tt'�,y.15 JL}, L'!t{ ft.). O'SStk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 � Appncant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave. P.O. Box 2009, Stk., CA 95201 NIL FEE CK 43 INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT-NO. + EH13-24 IRE'V.l i e 51 EH 14.28