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i } APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)465-34200a, P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DAJE ISSUED APR;; (Complete in Triplicate) ENVIRGNMEN AL HEALTH Application is hereby made to San Joaquin County for a permit to construct and/or install This application is made in Compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 12 n R I�ct___N-alam a_r_ _IQ14 a Lot Size/Acreage Owner's Name Ultramar Inc . Address 525 West Third StreetHanfoone 20 — —024 408-438-7511 Contracto I Address 269 Mounto hone TYPE OF WELL/PUMP: I� NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER)4 Monitoring Well C7 .i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /v" U1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation mania. of Weil Casing 1 12 in h 177 Domestic/Private �Gravel Pack ❑ Tracy Type of Casing especihcations l'1xPublic 4 r Other (� C;C t O n Depth of Grout Seal Type of Grou _ r y V a�Ah-h F r a C t i O n OF .Approx. Depth I I Eastern Surface Seal Installed by E V A X T a r h n a l n R jr Repair Work Done L3 Type of Pump H.P. State Wprk Done Welt Destruction ❑ Well Diameter Sealing Material & Depth Gement MNI D pth Filler Material & Depth C —,- —- TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) O Installation will serve: Residence_____ Commercial_ Other Number of living units: Number of bedrooms {� Character of soil to a depth)of 3 feet: Water table depth'P SEPTIC TANK. ❑ . Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal a Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ �No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 County 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 signature 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 California." ;iM The applicant mu or all.�re re s tions. Co late drawing on reverse side. I Signed x Title: Date:2 8 March 1991 i Owner/ EngQineering Contractor �( FOR DEP RTMENT USE ONLY Application Accepted by 9 Rj5h-� Date Area 9 Pit or Grout inspection by !� Date �� Final Inspection y Date Additional Comments: SII Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 t INF 0 AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'N0. I + EH 13-24(REV.I/F%5 EH 14.25 IFU& -7T