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z ' a' G 1' APPLICATION FOR PERMIT SAN JOAQUIN LOCAs. HEALTH DISTRICT r. 1607 E. FIAZEL T ON AVE., STOCKTON, CA Telephone (209}46#69e}?Li i y;zU PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heroin described,This application is marts in cnmplianee with San Joaquin County Ordinance No.549 for riewaga or N43.1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Jeb Address 950 11th Street City Tracy Lot Size 105X125' PM owner's Name Desert Petroleum Address P•0. Box 1601 , Oxnard CA 93032 Phone (805) 644-6784 CDnt-actor WESTERN GE0-ENGINEER%ddress$1:_2 BOX 17Z;Woodland. O19License Ne.513R57 Phone 1 TYPE OF WELL/PUMP: ni or NEW WELLS ree) WELL REPLACEMENT ❑ DESTRUCTION 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 25, ± DISPOSAL FLD.— PROP.LINE 10 f FOUNDATION 1 0 AGRICULTURE WELL T OTHER WELL PITSISUMPS 1 0 ± INTENDED USE (3) TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industria! Monitor 0 Open Bottom 0 Manteca Dia.of Well Excavation 7,7 18" 'Dill-of Well'Casing 201 - 0 " - 0 Domestic/Private IR Gravel Pack fy3 Tracy Type of Casing PVC Speciftcalions 11 Public 171 Other ❑Delta Depth of Grout Seal 8' Type of Grout Klett Benton/ I I Irrigation 26' each-Approx,Depth I I Eastern Surface Seal Installed by Driller Repair Work Done 0 Type of Pump None H.P. State Work Done Well Desiruction 0 Well Diameter Sealing Material(top 501 Depth Filler Material(Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDMON I I DESTRUCTION I 1 INo Septic system permitted if public sewer is available within 200 fact.) Installation will serve: Residence_ Commercial— Other ' Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No.Compartments PKG.TREATMENT PLT.Cs Method of Disposal Distance'to nearest: Well Foundation Property.Line LEACHING LINE 0 No.&Length of lines Total length/size FILTER BED i7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS [I Depth _Site Number SUMPS Ll Distanca to nearest: Well Foundation Property Line DISPOSAL PONDS 0 _ 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 Health District. Home owner or licenmd 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 workrnan's compensation laws of California,"Contractors hiring or sub-contracting 6gtrfature 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 Califer ' The applicant call r i �t17. Complete drawing on reverse side, Signad // Title:Pres_ WESTERN GF.(1_F.NC:INFFRG Dale; FOR DEPARTMENT USE ONLY Ap /tion Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date -,_dditional-Comments: 1 Sik 466-6781 0 Lodi 369-3621 ❑Manteca 823-7104 0 Tracy 835.6385 Applicant-Return all copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.Box 2009,Sik.,CA 95201 FEE INFOAMOUNT DUE AMOUNT REMITTED CASK RECEIVED BY RAT£ - •EN ik74 EH 14.26