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APPL I CATION FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONt1 <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 l. . <br /> l P O BOX 2009, STOCKTON, CA 95201 <br /> JUL 03 1991 <br /> .I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> j (Complete in Triplicate) I�'JIRQNMENTALi1EATH <br /> I t <br /> Application is hereby made`to San Joaquin County for a permit to construct and/or install the work 9tScA4 f/dWir= This ' <br /> application is made in coviliance with San Joaquin County Ordinance No. 519 and 1862 and the Rules and Regulations of San t <br /> Joaquin County Public Health Services. <br /> Il <br /> Job Address 1257 West ,Yosemite Ave City Manteca Lot Size/Acreage 140'X 140' {app r) <br /> Owner's Name Chevron USA !nc. Address P•0.Box 5004,San Ramon,CA94583 phone(415)842-8658 <br /> 11 Inc. 2150 W.Wintan <br /> -Ave.Haywar 220719 (415)783-750 <br /> Contractor& ettIer-Ryan, Address L�cense No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL X WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE10-201 <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n <br /> 211 <br /> n Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Ria. of Well Casing v� <br /> Il Domestic/Private ❑ Gravel Pack n Tracy Type of Casing PVC Specifications SCh4o <br /> I'I Public Xx Other I'1 Delta Depth of Grout Seal E/+T Type of Grout <br /> t I Irrigation �.Approx. Depth I I Eastern Surface Sea! Installed by / Gett l r-R an Inc. <br /> Repair Work Done 0 Type'lot Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth r <br /> TYPE OF SEPTIC WORK: . NEW INSTALLATION I i REPAIR/ADDITION I I ,DESTRUCTION [ I !No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation wdl;serve_.J Residence_ Commercial T Other <br /> Number-of li4iiig:units: �� Number of bedrooms <br /> Character;of soil"to'a depth of 3 feet: Water table depth F <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 I` Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE C1 Na. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line ' <br /> SEEPAGE PITS 11 Depth Sire Number <br /> a <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ II <br /> 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 <br /> rules and regulations of the San,°Joaquin County <br /> 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, l shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> 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- <br /> tion laws of California." <br /> The applicant m �a;lldlr inspections, mplet drawing on reverse side. <br /> Signed Title: Ur*4r Project Manager Date: July 1 , 1991 <br /> I` <br /> I FOR DEPARTMENT USE ONLY <br /> A 7ccy Date Area <br /> Pit or Grout Inspection by Date 7,L3 Final Inspection by Date -Z 3 <br /> Additional Comments: b <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> If Services, Environmental Health Permit/Services ! <br /> li 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. I <br /> . EH19.21 INEY.1/HSI M <br /> EH N-2e r 11 <br />