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z ! <br /> APPLIC:-NTIQ I '. <br /> SAN' JOARUIN"CDUNTY PUBLIC HEALTH SERVICES . <br /> ENVIBONVOTAL STALTH DIVISION <br /> 445 N SAN rIOAQU IPI: PH4NT (209)468-3420 <br /> 5'e, <br /> p O BOX 2009, STOCKTONN. CA 95201 <br /> f p ykR FR <br /> (Complete in Triplicate) <br /> i <br /> work herein described. This <br /> Applies is hereby mode.to San Joaquin C=ty for a Permit to construct andlor install the <br /> Applicstiao Ss meds in c llanee with HeA csquin County ordinate No. 549 and 1852 atld the Rules aatd Regulations of San <br /> Jae4uitt CauutY Public Health Services. . Stockton Gas Station <br /> City Lot Site/Acreage <br /> 2185 E. Fremont, Street 93232 <br /> Jae Address 209/582-0241 <br /> Ultramar Inc Address <br /> 525 W. 3rd-St. Hanford, CA Phone <br /> owner's Nam* 5 �ita gggRG#4860 408/458-161 <br /> $ A1� UzA ObS license No. Poona <br /> RTD Inc. Address <br /> /Contractor WELt R€PLACEMENT C� OESTRUCnON C3 Out or Service, well <br /> NEW WELL OTHER Cl Mossltoring Well C]TYPE OF WELDPUMP: SYSTEM REPAIR 0 <br /> PUMP INSTALLATION G pISPOSAL FLR--�— PROP. LINE <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES --- PIMSUMPSAGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> LL OF WELL PRO8LEM AREA CONSTRUCTION SPECIFICATIONS Dia. of We" Casing <br /> INTENDED USE - — — pia. of Well Excavataan <br /> C1 Indusrner O 0 n Bottom G Manteca Specificititrns--- <br /> C7 Gravel act ❑ Tracy Type of Casing_ <br /> f i Domestic/Priwta � TypF of Grout <br /> I'll Other I ("' 04us 060th of Grout Seat � <br /> PtAhk Surface Soul Installed by O( <br /> 3 I lnit}utian —ApprgK. Depth l l Eastern ats 1/1lark Don! <br /> H.P. $t <br /> Repair Work Done 17 Type of Pump Staling Material A Depth <br /> Well Destruction O Well Diameter �.� <br /> Depth Filler Material i AePth <br /> 7YPE OF SEPTIC WORK; NEW tNSTALLAT10N i r pEPAIA/AOOITION l I DESTAUCTION I I iNo seplic system p6rmilied if public te,wer is � <br /> available,within 200 feet.) <br /> InsWation will serve: Residence, CommercW Other \ <br /> Number of living unite: Number of badroor*n Water table doth <br /> Character of soli to a depth of 3 hoar. Capacity,-- No. Umpartmerm <br /> SEPTIC TANK. ❑ Typed Mfg <br /> Method of Qitlposal <br /> PKG. TREATMENT PLT.0 <br />` Distance to nearest Walt Foundation __ Property Lime�. <br /> Total length/W <br /> n <br /> LEACHING LINE C7 No. b iLangtlines Property Li0s�.�.— <br /> FILTER BED 0 Distance to <br /> nearest. Well .^ Foundation -- <br /> SEEPAGE PITS 11 Depth Sim Number <br /> SUMPS LI Distance to nearest: Well — Foundal"m Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby esrtify that I have prepared this application land that the work will be dans in eccardencs with San Joaquin county ortlinsricea, state laws. and <br /> rules and regulations of Inc San Joaquin CounvY <br /> home owner or licensed agent's signature unifies the following; "i certify that In the portormanu Of the ylrgrk Taf Which this permit K iaaue,d. I ac n tu14ra <br /> employ any person in Such manner asato become subvaCt to workman's compensation laws of California." Contract a t ta�rvorktmsn'iComOMsa <br /> certifies the following: "I certify trial in the parformancs of the work for which this permit is issued, i shall employ ps <br /> lion laws of Casifomla", <br /> The eppllcaAt s call for I ad inspections. Compote drawing on reverse side• 3/15/93 <br /> Signed Till.: Princioal Geologist Dow <br /> FOR DEPARTMENT USE ONLY 3 <br /> � <br /> Application Accepted by Dots Area` �7 <br /> Ph or Grout lnspscilan by L Date Final Inspection by DAtf <br /> a <br /> Additional Comrnents, 0 <br /> Applicant - Return all COpies to: San Joaquin CoUntY Public Health services a <br /> savironroental Health Permit/9erviaes <br /> 445 N San Joaquin, P O Box 2008, Stkn, CA 85241 <br /> FSiE K RECEIVEO Illy GATE PERhtfT'NO. <br /> INFO AMOUNT 06E AMOUNT REINITTED GASH <br /> . EN 1244 IRM.I/rya <br />