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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 3601 p•0 BOXL2009, STOCKTON, CA0rS424 95201 R B R (Complete 10 Triplicate) Application is hereby made to San Joaquin county for a permit to construct and/or iaatall the work herein described. This application is oLde in costpliance vtth San Joaquin County Ordinance NO. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. I Job Address 500 East Gri�rttline Road C;ty Tra Lot size/Acreage ~1 d SO 700 SUrbaA�ione 818 S3- 6 6 Owner's Name Mobil Oil CA ration Address 3800 V+J• Alamt.�da Suite Contractor W.Hazmat Drilling Address 23953 Saklan Road'Ha al[ enst No. —5-549-79 Pnon 510 782-877 TYPE OF WELL/PUMP' NEW WELL ❑ WELL REPLACEMENT ❑ OESTRUCTION ❑ Out of service Well Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ Soil Borit#rHER [3 anile 5' DISPOSAL FLD. 1 Ml- 1 PROP. LINE 10 DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES ------ lmi• PITSISUMPS 0.5mi• FOUNDATION 501_�- AGRICULTURE WELL 0'5M'• OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N/A � — O;a. of Well Excavation Dia. of WON Casing C3 Industrial Open Bottom ❑ Manteca - T of Casing N/A Specifications. Cl Domestic/Privam ER Gravel Pack (11 Tracy y>� 10' Type of Grout Neat Gement i'I Public f] Other ll Delta Depth of Grout Seal I I trrpatron 10'Approe. Depth I I Eastern Surface Sesl Installed by NIA 1 1 ring O Repair Work Done U Type of Pump H.P. N A N+}A work Done 'rou Wl neat Sealing Maserial It Depth Wad Destruction O Wen Diameter ?ills' Material } Depth N/A cement. Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION I i available within 200 leet�l� d pubtiC sewer is Instaastion wig serve: Aesidence_ Commercial---- Other Number of living units: Number of bedrooms Water table depth Ctusracter of $oli to a depth of 3 feet: No. Compartments SEPTIC: TANK [3TypelMfg Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Wen Foundation Property Line PAVIAi LEACHING LINE 0 No. i Length of linea Total length/si: FILTER BED 0 Distance to nearest: WM Foundation Props Ine SEEPAGE PITS 11 Depth .� sit. Number 1 SUMPS LI Distance to nearest: Wed Foundation PP rEihiE&MiS�'V10ES "--�—ENVI ONMENTAL HEALTH DIViC.' DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this spplrcation and that the work win be done in accordance with San Joaquin county ordinance!, state laws, and rules and regulswns of the San Joaquin County Hone owner or licensed agent's signature certifies the lodow;np: "1 certify chat;n the plsrformance to the work for which this permit is issued, i shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub contracting signature certifies the foGowing: "I certify that in the performance of the work tot which this permit is issued,I shall employ Persona subject to workman's compensa tion lows of California," Geologist Dat.: The epO! st d for M wired inspections. Complete drawing on Senior side. 3-25-92 'r Signed Title: FOR DEPARTMENT USE ONLY Date �� I [ Z_ _ Area Application Accepted by !tit or Grout [rtspect;on by Date ._ Foal Inspection by Date Additional Conw*nu: Applicant - Return ell copiu to: San Joaquin County Public Realtls Serrices, lavirowwntal Sealth Penait/Serviced �� J 3603 t. laselton Ave.. P 0 BO: 2009, StocKton, CA 95201 11 FEEK RECEIVED Illy DATE PERMIT-NO. AAAOUNT DtJE Atr1011NT REMITTED H INFO�12t I Ex �U �q. G� X23 __Mal 33[ �Z q2-G63 • Exna�.1/R}1