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----------- ------ -- ------ ------------ ------ i �. APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA :i Tei^phone (209) 461$6-M4 3WO i 1Y.2- PERMIT EXPIRES 1 YEAR FROM DATE ISSUED W�IComplete in Triplicate) Application is,hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in cbmplianee with San Joaquin Co{inty Ordinance No.549 lof sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _950 11 th Street City Tracy Lot Silo 1 05x1 25� pm Owner's Name Address � Phone Desert Petroleum P,O, Box 1601 Oxnard CA 93032 (805) 644-6784 Coniracta WESTERN GEO—ENGINEERcddressRt_2 Box 17 Woodland,_S2�icense No.513857 Phone 662-45#1 _ ?,,_ TYPE OF WELL/PUMP; monitor NEW WELLe ree I WELL REPLACEMENT D DESTRUCTION Q PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 25' DISPOSAL FLD._ PROP. LINE 10 FOUNDATION 10 t AGRICULTURE WELL OTHER WELL PITS/SUMPS Lo ¢ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Induttrial Monitdx ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7-7J8" ___ Dia,of Wall Casing 211 j ❑ VnMastic/Private (R Gravel Pack Q Tracy Type of Casing PVC Specifications f'1 Public fl Other n Delta Depth of Grout Seal 8' Type of Grout Neat 13entona i I Irrigation 26' each-Approa. Depth I I Eastern Surface Seat Installed by Driller Repair Work Done L3 Type of Pump Nane H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material(top 50 _ Depth Filler Mataiial l8elow 501 TYPE OF.SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I I Mo septic system permitted if public$+ewer is available within 200 feet,) Il` r Installation wili serve: Residence_ Commercial_ Other ' i - Number of living units: ______ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ TWelMfg _ _ Capacity No.compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property-Line —_ LEACHING LINE ❑ No. hi Length of lines __ Total length/size FILTER BED ❑ Distance to nearesl: Well Foundation Property Line a SEEPAGE PITS I I Depth _Size —_- --- _- Number SUMPS Ll Distance to nearest: Well Foundation Property Lino DISPOSAL PONDS CI 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 Hea},h District. 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 laws of California."Contractor's hiring or sub-contracting sigrfi,tura 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 Califor ' The applicant call r io . Complete drawing on reverse side, Signed Title: Pres- WESTERN GED—ENGTNEEI7S Date, 4Z29188 .,. FOR DEPARTMENT USE ONLY i App cation Accepted by Date Area Pit or Grout Inspection by - Date Final Inspection by_ — Date. dditional Comments: J Sik 466-6781 ❑ Lodi 369.3621 ❑ Manteca 023-7104 0 Tracy 1335-6385 I Applicant- Return all Copies to: Environment6i Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. - } INFO CASH EH 13-�A rREV.e,n 5I kH 14.26 i 1