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' APPLIG1TTON SAN JOAQUIN COUNTY PUBLIC HSALTE SERVICE81, ENVIRONMENTAL REACTS DIVISION 1� y 445 N SAN JOAQUIN, PSONT (209)468-3420 P O BOX 20091 STOCKTON, CA 95201 I pir IT MlgEg I YEAR FROM (Complete in Triplicate) Appliestion is hereby made to Ww Joaquin County for a permit to construct and/or install the work herein described. This applicstion is sada in coaiplianee with Bap Joaquin County OrdIn"ce No. 549 and 1$62 end the Hulas and RegUlatione of San Joaquin County Public Health Services ' Job Address 2185 E. Fremont Street city Stockton Lot site/Acreage Gas Station Ultramar Inc! 525 W. 3rd St. Hanford, CA93232Phond 209/582-0241 Ownef's Name Address - I Contractor RTO Inc. Address g �italeuzA b 65 License No RG#4860 Phone 40$/458--161 TYPE OF WELL/PUMP NEW WELL O WELL REPLACEMENT El OESTRUCTION Cl Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER R 1lottitarind Well ❑ ' DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLq PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL— PITS/SUMPS — iNTENO20 USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' Cl industrial O Open Bottom ❑ Manteca Die of Well Excavation Dia of WON COWV f1 OorriesdclPrivate ❑ Gravel Race C] Tracy Type of Casing_ Specifications I i Pubk 1"1 Other n Delia Depth of Grout Seat Type of Grout I I Irrigallon —Apprga Depth t I Eastern Surface Saul Installed by ` Repair Work Done f] Type of Pump N P State Work Bone Well Destruction C] Weft Dtamstsr sealing Ilsterti l E Depth Vl Depth filler material i jlepth PA OF 5EPTIC WORK NEW INSTALLATION I I REPAIR/ADOtTION l i DESTRUCTION I I INo esprit system perrrutted it public sewer a avaeable within 200 lost ins%lietion will serve Residence Coinmeralal_ Other Numbp of living unite Nwnber of badrowns Character of sill to a depth of 3 fact' Water liable depth rSEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG TREATMENT PLT Cl i Method of Diva" Distance to nearest Well Foundation Property Line , LEACHING LINE Cl No A iongih of linea Total length/else � FILTER $IED O Distance to nearest' Well Founaaitmm— Property Lino SEEPAGE PITS I I Depth size Number SUMPS LI Distance to neefest' Well Foundation Property Line ' DISPOSAL PONDS ❑ I hereby certify Chet I hew prepared tris application and that the work will be done in accordance with San Joaquin county oidMancss. slate taws, and rules end regulations of the San Joaquin Comvy Mom*ownor or Iicensad agent's signature certifies,he following "I certify the,In the performance of the woik for which three pOrmrt la issued. I shag not emliloy any parson M such manner as to become subject to workman's compensation laws of California"Contractor's hiring or auDCOneraetxq signature c"Ites the following "I certify that in the perlormeaee of the work for which this permit Is issued,I shag smMay persons subject to workman a compensa lion laws of Calrfornla" The appllcant cell fo spactions Complete drewing on reverse side tsron.a Title Principal Geologist ata. 3/15/93 FOR DEPARTMENT USE ONLyDate 3-17 f Arse JWApolwon oAccepted by XZ'4'� I It or Grout Inspection by I Date Final Inapectbn by Data Additional Comn*nts Applicant - Return all copies to San Joaquin County Public Health ffervicesO� Environmental Health Permit/Servicedf s 445 W San Joaquin. P O box 2009, Stxn, CA 95201 ' rtEfi AMOUNT DUE AMOUNT ItEMITT10 C K I AIcirveO AY DATE ►fiRfrel7 NO INFO . IN t2-24 1111v i,otli 07- �9.oa (Ill ' -l�'3n�&)