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------------- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION(a py <br /> 150:1 E. HAZELTON AVE. , PHONE (209)468--5420 w <br /> P U BOR 2009, S'1'UCHTUN, CA 6203 <br /> PERMIT- YMP- RS 1 YEAR FRQX ATE ISSUED <br /> {Complete in Trfplicte) <br /> Application is hereby made,to Sen Joaquin County Tor a permit to construct end/or install the work herein described. This <br /> application is made in eatepliance with Ban Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 950 11th Street City Tracy Lot Size/Acreage <br /> Owner's Name Desert Petroleum Addloss P.O. Box 1601 , Oxnard, CA 930 Phone _(805_) 64_4-6784 <br /> Contractor„West JLzmat Address 3233 EL <br /> tggWld St. Smcn License No. Phone_ 916 638-7271 <br /> ` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,_ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ZPr <br /> Cl Industrial C1 Opon Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing S) <br /> r i Domestic/Private Cl Gravel Pack In Tracy Type of Casing. 21' P17C5pacilicerions �] 40 PVC <br /> I'1 Public IA Other Il Delta Depth of Grout Seal 8' Type of Grout <br /> I I Irrigation __Approx. Depth I I Eastern Surface Saul Installed by <br /> Repair Work Hone L] Type of Pu.np N/A H,P, Slate Work Dons <br /> Well Damlruetian ❑ Well Diameter S" Sealing Material i Depth <br /> Depth 15 Filler Material i Depth �-- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Inslsllatian ill serve: Residence— Commtircial_ Other <br /> Numberof livi�dapth <br /> umber of bedrooms n <br /> Character of Bas • Water table depth <br /> SEPTIC TANK ❑ T 61110111 '_Capatity No. Compartments <br /> PKG. TREATMENT PLT.Ll � Method of Disposal ] <br /> Distance to nearest: Well�` FoundAflon Property Lin- <br /> T --} <br /> ��•C - -- G 6�1 r <br /> LEACHING LINE it No. 6 LLengKr f tines Total length/Size RECEIVED <br /> FILTER HED 0 I t4E ante to nearest: Well Foundation Pro a LI <br /> p rty n <br /> 6-IhIR <br /> p �9�p u 9 <br /> t,I <br /> J <br /> SEEPAGI I Depth Size Number SAN JOA tliN COUNTY <br /> SUfs1 S LI Distance to nearest: Well Founds+ion Pro ICES <br /> DIVISION <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that i hgve prepared this application acid 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 canifies the following: "I certify that in the performance of the work for which this permit is issued, I shell 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 III Issued,I shall employ parsonri subject to workmen's compenes, <br /> tion lewa of California." <br /> The applicant must for all required irWQ!efi0m-6emplate drawing on reverse side. <br /> Signed XTitle: _ ! Dale: <br /> FOR DEPARTMENT USE ONLY <br /> '33Application Accepted by Oale `; [ Area ` <br /> Pit or Grout inspection by Date Final Inspection by Date_ <br /> Additional Comments: <br /> Applicant - Return all copies to: Ban Joaquin County Public IlealthSery �ffl <br /> 16011ces,E. HazzeeltonvironAve� ,1PR0Box 2009, <br /> alth tStockton, CA 95201 �r ©`-'///t1 <br /> FEE AMOUNT DUE AM CK <br /> INFO OUNT REMITTED CASK RECEIVED BY DATE PERMII'NO. <br /> 1pqEH 17 f4 IItEV.r/a 41 /\ �j �(� <br /> i <br />