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APPLICATION FOR PSBi[IT <br /> 4 <br /> 1440 <br /> SAN JOAQUIN COMITY MMIC HEALTH SERVI <br /> ENVIRONMENTAL HEALTH DIVISION iYMEDVT <br /> \ U 1601 E HAZBLTOAN AVE. , PHONE (209)4681MEI VE D <br /> P Q BOX 2009, STOCKTON, CA 95201 <br /> MAR 0 9 IM <br /> PARK SZ RBA i YAR FROM .RATS ISIMU.AQU1N COUNTY <br /> (Complete in Triplicate) <br /> Fpp��PU8L1Cc[►rH LTH S£R1/�CEg <br /> Application is hereby aide to Bion Joaquin County for a perlait to construct and/of*'3�iMLT44ti'{ 46PAS) bed. This <br /> application is rade in coapliance vith San Joaquin County Ordinance Mo. 549 and 1862 and the Rules and AedMu2s�tions of San <br /> Joaquin County Public Health Services. <br /> Job Address 950 11th Street city Tracy Lot Size/Acreage <br /> Owner's Nerve Desert Petroleum Address P.O. Box 1601 , Oxnard, CA 9303 (805) 644-6784 <br /> Contractor West Hazmat Address License No. 554979 (_C57) Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL R6PLACYd#NM OESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ig <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 231 r <br /> • Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing <br /> O Domestic/Private ❑ Gravel Pack 9 Tracy Type of Casing 2" PI- Specifications-Sch 40 PX � <br /> Il Public M Other ❑ Delta 8' `/ <br /> Depth of Grout Seal Type of Grout..�N� <br /> I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by ` mmis <br /> Repair Work Done U Type of Pump IQ& _ H.P. State Work Done_ <br /> WON Destruction O WON Diameter 8" Sealing Material i Depth ,Pard-r-Ini+2 Pella" <br /> Depth 15' totter Naterlal i Depth #3 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i 1 DESTRUCTION t I (No septic system permitted if public sever is <br /> available within 200 fast.) <br /> Installation aerw: Residence_ Comrnerciai_ Other <br /> Number of Number of bedrooms r <br /> Character of eoN to a depth o Water table depth <br /> SEPTIC TANK. O Type/Mfgity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: tion Property Lino — <br /> LEACHING LINE 0 No. 8 of Imes Total lengthlsize <br /> FILTER HED ❑ to rarest: Well Foundation Property Line <br /> SEEPA I I Depth Sine Number <br /> S Ll Distance to nearest: WON Foundation Property Line <br /> "DISPOSAL PONDS ❑ <br /> 1 hereby ter that I have prepared this application and that the work will be date in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or Yraesed agent's signature certifies the following: "I carufy that in the performance of the work for which this permit is issued.1 shall not <br /> employ any person in such manner as to become subject to workman's compensation Was of Catifomis." Contractors haing or sub-contracting sWwttu* <br /> eerd8ts the faftwitg:"I Certify that in the perfonmance of the work for which this permit is issued.I shall employ persons subject to workman's comperes- <br /> tion laws of Calillorraa." <br /> The sPP*W t must Nor ale required inWeWait Complete drawing an reverse sift. <br /> Signed X Tide: /d2eCr 23;i4 _ yL Date: <br /> FOR DEPARTMENT USE ONLY ,.-. <br /> Application Accept"by Data ` 3 �Area <br /> Pit or Grout atao.ction by Data FW inspection by `SE's 'T '�L��� �y°[` Dale <br /> Additional Comments: <br /> Applicant - Return all copier to: San Joaquin County Public Health <br /> Serrices, Amirotsental Health POrtait/Services O <br /> 16M E. Haselton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> INFO <br /> A�M(OODU{NT DUE AMOUNT}REMITTED CK S CASH RECEIVED BY DATE PERMIT'N0. <br /> .EN 1Y211ttlV.�isa� CJ (` Cu !� Oo Z�3 <br /> pr:4a1 <br />