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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICMt�°°,A��= ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-RECEIVED P O BOR 2009, STOCKTON, CA 95201 MAR 0 9 1993 SPIRES 1 YEAR FR M DATE (Complete in Triplicate) UNTY PUBLIC H LTH SERVICES Application is hereby made.to San Joaquin County for a permit to construct and/or bed. This application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i Joaquin County Public Health Services. Job Address 950 11th Street City Tracy Lot Size/Acreage Owner's Name Desert Petroleum Address P.O. Box 1601 , Oxnard, CA 9303ahone (805) 644-6784 Contractor West H zmat Address 3233 Ej ld Sir Ranctio License No. 554979 (C57) Phone (916) 638-727 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2„ CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel Pack N Tracy Type of Casing 2" PVC Specifications Sedi 40 PVC I'l Public f-1 Other n Delta Depth of Grout Seal 8' Type of Grout N o t. I I trrigation __.Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump NZA H.P. State Work Done _ Well Destruction ❑ Well Diameter 8" Sealing Material & Depth aMt=ite pep QtS Depth 15, Filler Material & Depth #3 mmtm:r-atxl TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I i INo septic system permitted if public sewer is e available within 200 feet.I installatibn, ill serve: Residence— Commercial— Other Number of living Number of bedrooms Yr�� Character of soil to a�daplh �� Water table depth SEPTIC TANK. pe/Mfg acity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal j Distance to nearest: W Foun 'on— Property Line I LEACHING LINE _❑ No. & L of lines Total length/Mze- 1 FILTER BED 1-1 tance to nearest: Well Foundation Property Line SEEPAGE I I Depth Size Number S S 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 County 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 taws 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." The applicant must c for all required inamcsions--Gemplete drawing on reverse side. Signed X. Title: ic�o„ Date: FOR DEPARTMENT USE ONLY r- 7 Application Accepted by Date � � Area Pit or Grout Inspection by Date slA 5 5 Final Inspection by �ti`� pate / Additional Comments: r Applicant - Return all copies to: San Joaquin County Public Health /1 Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO ST FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY pATE PERMIT'N0. a EH 13,24 1rtEV. /n Sr EH 1.4,26 I