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APPLICATION FOR PERUIT SAN JOAQUIN COQNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL gEALTH DIVISION 1601 E. HAZFLT©N AVE. , PHONE CA09)468-3420 P 0 HOZ 2009, STOCKTON, 5201 Id pATS ISSUED ME Triplicate) (Complete in Trip Application is hereby made to San Joaquin CountT for a permit to construct and/or install the work herein described. This application is made in eotapliaace with 3" Joaquin Couaty Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. l50 t x150 r Job Address 500 East Grantline Road city Trate Lot Sise/Acreage o�nrne:a Nar++e Mobil Oil Corporation Address 3800 yl,plameda,Suite 700,Burbankphone (818)953--2626 Contractor W.Razmat Drilling Address 23953 Saklan Rd. ,HaywardLice'SO No. 554979 Pho,4 510)782-877C TYPE OF WEtLIPUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or Service Yeil ❑� OTHER ❑ lionitoring Well SYSTEM REPAIR ❑ r PUMP INSTALLJ�TION,O 2Cj I 1 �• PROP. LINE �'� pISTANCE TO NEAREST: SEPTIC TANK 1 M1 SEWER LINES ml.DISPOSAL FLO. FOUNDATION AGRICULTURE wElt OTHER WELLlml•, PITS/SUMPS .5�1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well E><cavation Dia. of Well CA" n Industnas ❑ Open Bonorn ❑ Manteca Y Specifications Type of Casing at Cement ri Domestic/Private M Gravel Pact �! Tracy Depth of Grout Seal _ Type,of Grou _ it Prrblic In other n Delta West Razlnat Drilling ! 351 Approx. Depth I I Eastern Surface Seui Installed by trr�atwn State Wart Done Repave Work Don* U Type at Pump H.P !----vial--------- -- Ar WIN Diameter sealing --vial i Depth_ Watt Destruction ❑ Piller Ifaterial i Depth Depth YP£ OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADOtTkON I I DESTRUCTION I I sN+,�dsbpi�vwslytune200 Igtt`ed if puplit save+ is Installation win serve: Residence-- Commercial— Other�.�— Number of Yvinq units: Number of bedrooms -- Water table depth �A CrarIcte, of Wes to a depth of 3 feet: Co++�O+Krr+enn SEPTIC TANK ❑ TYM/Mf4 GpAcity� �— M I rift E PKC. TREATMENT PLT.❑ Property Distance to nearest: We4 Foundation LEACHING LINE ❑ No. •Length of linty Total length/ 16 44 FILTER BED ❑ Distance to nearest: Wed Foundation - Pro§NR��Msr Size Num ryN CIN SEEPAGE PITS I 1 Depth Property LirN 11A SUMPS Ll Distance to neorest: Wort Foundation DISPOSAL PONDS ❑ t the work will be done in accordance with San Joaquin county ordinance. Etats laws, and I hereby conity that I have prepared this Application and tha rules and regulations of the San Joaquin County not Horne owner or ticensed&"nt's signslura cenifNs the foNow;ng: '9 Certify that in the paws at encs rn the work for which this permit's ractN signature employ any person in such manner as to become WNW SO w 0r`krman'a compensation laws ss ed,I shall Contract scRu subjring ect to�workman's COMPO+ia certifies the folo,ving: "I certify that;n the perlormance of the work for which this permit is issued, I shorty ernpby W N tion laws of Cafilonis." The appliun c for at in pettions• Corr+plete drawing on reverse side. 3-25-92 Signed Title: Senior Geologist Date: FOR DEPARTMENT USE ONLY Date Ara n 6 Appineation Accepted try � '" — - PIR or Grout Inspection by .., Date_- Final InsPoc ion by pace Additions- Comments: APplicaat - Return all caplea to: San Joaquia County Public Smith Services, Ravirootaeotal Eealth Perait/Services 1601 S. lfaselton Ave.. F 0 Box 2009- Stockton, CA 95201 FEE is RECEIVED BY GATE PERtu'r,"O. IEEENFO AMouNT p AMOUNT REMITTED N ��Der-- acv 2� -2YJ�'1 97-063 EM,sza��tV.�,�s�