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r <br /> APPLICATION FOR PIT �/ p <br /> SAN JOAQUIN COUNTY PUBLIC CL <br /> 1g�N� � N SANENVJ�OAQUIN, PHONES I, HEALTH (20 o <br /> �! � �V110 <br /> \ P o BOX 2009, STOCNTON, <br /> Ac �v <br /> vP ��1a+F��'�� P T M D .� <br /> 1R�Nt� (Complete in Triplica e <br /> A cItion is hereby made to San Joaquin County for a permit to constructL44&WA6==j <br /> application is made in cottrpliamce with San Joaquin County Ordinance No. 549 ea Rer6ulatians of Ban <br /> Joaquin County Public Health Services. <br /> 200' S/0 PETE�7 MILLER RD.&150'E/O I-5 <br /> .lob AtWresa City Lot Size/Acrearse <br /> Ow,.•S�,m CHEVRON PIPELINE COMPANY Addre,s 2350 BUCHANAN RD. P� 510 827-6195 <br /> on raclor.-CMST_& SiIP'Pi.y INC Address 1038 RFTYWOOT) MN *2 License No. _3105599 _Phoma 38 <br /> TYPE OF WELL/PUMP: NEW WELL)a WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Tall ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ N/A SEWER LINES N/A DISPOSAL FLO. N/A_ PROP. LINE LLA <br /> FOUNDATION —VA.— AGRICULTURE WELL _NL&_ OTHER WE•LL--XLA.. PITS/SUMPS ILA <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFlCAnONS <br /> 0 Industrial 0 Open Bottom L Manteca Dia. of Well Excavation Dia. of War Casing 2ft <br /> [:] Domaswipfl►rats ❑ Gravel Pack ❑ Tracy Type of Casing PVC - Speciticetlons Ct'xf <br /> N Public 11Other CATHODIC n Deft% Depth of Grout Seal ._-100'___ Type of Grout 6 RR 3/R'r f'11i <br /> I I Irrigation —Approx. Depth I I Eastern Surface See] installed by TREKTR <br /> Repair Work Dons * Type of Pump N.P. State Work Dons <br /> Wall Destruction p Weft Diameter whaling Material i Depth <br /> Depth <br /> nllem Naterial i Depth <br /> TYPE OF SEPTIC WORK- NEW INSTALLATION I I REPAIRrADDITION I I DESTRUCTION I I (No septic system permitted If public sewer is <br /> N/A evadable within 200 loot.) <br /> Installation wIR sm : Residence Commercial— Other _ <br /> Number of" units: Number of bedrooms <br /> Character of NO to a depth of 3 feet: Water table depth <br /> SEPTIC TANK- ❑ Type/Mfg o. ComInwo tetnta <br /> PKG. TREATMENT PLT.❑ lathod of Dhpoae] <br /> Obtance to nearest: P. <br /> aProperty Lina QS <br /> LEACHING LINE ❑ No. 6 Length of Lina Ajullly . SI, /size <br /> FILTER BED N/A O OWence to nearest: 11VIron F <br /> lid <br /> SEEPAGE PITS I l Depth size Number. <br /> SUMPS NIA Ll Distance to nowAn: Well Foundation <br /> Pro�psrty Line. <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, mate ism, and <br /> rules and regulstiorts of the Sen Joaquin county <br /> Harte owner or licauad agom's signature certifies the fcnawing: "I certify that in the performance of the work foc which Oft permit Is issued, I sW not <br /> may any person in such mer„oar ag to become subject to workman's compensmilon laws of California."Contractors hiring or sub-commictirM signature <br /> owtifiss the following:"I certify than In Ito performance of the work for which this pemdt is Issued,I shall employ periods subject to workntert's compensa- <br /> doh ism of Calif <br /> The mpp[icant f i spe.c6ons. Complete drawing on reverse aide_ <br /> slp,tsd 7 % STEVE M KIM Title: PROJECT MANAGER Date: _Ii/30/9 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accaptad by Date Area <br /> Pit or Grad lnwpection by Date Final Inspection by Date <br /> Addiibnel Carrpnen$: <br /> Applicant - Return, all copies to: San Joaquin County Public Health Services <br /> 'PIP* <br /> Rnvironmeutal Health Permit/Services <br /> 448 P Baa Joaquin, P O Bwr 2009, Stkn, CA 85201 ,E .rL <br /> 0 zf <br /> 4 INFO AMOUNT DUE AMOUNT REMITTED CASH RECOVED BY DATE PERM17-NO. � 7.1 <br /> . ' f&9- <br />