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APPLICATION TOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009; STOMON, CA 95201 <br /> (209) 468-344TV TSSUED <br /> •��'� <br /> ,I <br /> IT IRES I YEAR PROM DA <br /> (Compldze in Triplicate) <br /> Applicasion is hereby made to Sao Joaquin Countr for a permit to construct and/or install the varlt herein described. :•%Is <br /> a-pplicaslan is mrd* in ccaspliance with Sou Joaquin County Ordlnance Ifo. 549 and 1862 aad the Rules Rad Regulatiatte of San <br /> Joaquin County Public HGALLP Servieesti rp <br /> iL'T "t `;tY„ Manteca Lot SizaiAereageC <br /> J00 Address <br /> 14800 <br /> Moore Petroleum Inc:Address 5491 F Street, Banta, CA Phone 209--835-275Q <br /> Owned& Nance 916- <br /> 3653 Omer Circle F'�1 _gS4F <br /> Contractor R <br /> address Cordova License M051 9 4 2 S Phone._ <br /> TYPE OF WELL,PUMP: NEW WELL 4S WELL REPLACEMENT DESTRUCTION G:Out or Service we <br /> C <br /> PUMP INSTALLATION C SYSTEM REPAIR G OTHER ❑, youitOri well <br /> DISTANCE TO NEAREST: SEPTIC TANK �...� SEWER LINES DISPOSAL fLO, PROP. LINE <br /> FOUNDATION AGRiCL'LTURE WELL OTHER WELL PITSISUMPS <br /> tNTENOED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS 4 it <br /> i7: industrial Dia. o!Well Casio <br /> ❑ Open Bottom Manteca Oia. of Well Excavatan�.Q" - 9 i <br /> SDecittcations. <br /> X: OomasireJP*+vase %XGravoi Pack <br /> D Trtrcy Type of Casing ; <br /> Public (monitor V-1 Other C1 Delta Death of Grout Sear ' Type of Grout.f.�..,ot,+ + <br /> i <br /> trr+pation —Avoroz. Death C2Eastern Surface Soul Installed ov <br /> :F ' <br /> Rsasir Wort Oona '0 Type State Work Oona Type of Pump � <br /> Well Oostruction ❑ Well Diameter S* �S ltaurial i Deptls , <br /> D*oin <br /> Fillar Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION iJ AiEPAFRIAGOITION C. DESTRUCTION Z; INo sedalc sysiem veiminoo to puolic sewer Is <br /> avaiaom within 200 festa <br /> i I <br /> installation wal server Residence- Commercial Other i <br /> i <br /> Numoor at liwng uncle: Numasr at bitdraams <br /> Charseter at soil to a devin of 3 foot: Water tstale aeoth <br /> SEPTIC TANK © TAwMfg CaoacrNo. Comoarmnents <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Weil Founant+on Proosity Line <br /> LEACHING LINE Cl No. 6 Length of linos Total iengihrsize <br /> FILTER BED n Distance to nearest: Well Foundation — Proaerty Line <br /> SEEPAGE PITS it Death - Size Numaer <br /> SUMPS Ll Distance to nearest: Won Foundation Pracerty Line <br /> DISPOSAL PONOS 0 'p <br /> I ner*ov canny inert► have oreoarea tnts aaoncanort and.trial ins wore ww os non* in accordance with San Joaouin county ordinances. &tate taws. ane <br /> rules and regulations of the San JO&duer County F <br /> Meme owner or itcsnsoo sgent's signature raridws me fouowmg; 'I eertity that in ins oanormance at Ins worm for which this Derma is issued. I shau not <br /> omaloy any awson in such manner oz to became suawic to worernarr s comoensation laws of California." Contractors hiring or sub-conrrecting signature <br /> cgnilles ins fdtiOwing:"I certify Inat in Ins peAdrmance at Ins wore for wnren tars oormrt is issued.1 snail amplov persons suolect to wartman a comaensa- <br /> Tion isvirs of California.•' <br /> The appncsnt at call for ail requueo spections. Comalets aravang on warm side. <br /> Signed <br /> Date: <br /> FOR OF/PARTMENY USE ONLY <br /> Aaptreatian Aecsoted ov r Date `� Area <br /> Pit or Grout Inaaoetion oy wL Oaie 1 �S Final inso*cuon by Date ' <br /> Additional Carrinnents: " <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 443 N SAN JOAQUIN, P 0 BOIL 2008, STL=TON, CA 95101 <br /> 3 <br /> r`EE i AµOUNT Ot1E AMOLINT Remir^TEC -x a RECEIVED ey I GATE j1 PfRrrel7 NlSr l <br />