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! APPLICATION FOR PERMIT y SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT 1601 E. HAZEL T ON AVE., STOCKTON, CA RECEIVED Telephone (209) X166-6781 01 2 ct PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f�' 1 �`.' � FOR MONITORING WELLS (Complete in Triplicate) SAN -K- "':'-i ' NT's } PU BL IG HL'tai.!y qo.;OVII jClY/ES I�VI r )'h� lJC[14 'IIS dFiL [ Application Is hereby made To the San oaousn Local Hearth District for a permit to construct arta.or install rI{ bRfllfielr�n+de�gerr ran is made in compliance with San Joaquin Counry Ordinance No, 549 for sewage or No. 1862 for well,purno and the Ruies and Regulations of the San Joaquin Local Health District. Job Address 500 EAST GRANTLINE ROAD City TRACY Lot Size 150 x150 r PM Owner's Name MOBIL OIL CORPORATION Address 3800 W.ALAMEDA,STE.700,MRBANK Phone 818-953-2626 Contractor A'TON GEOSCIENCE Address 1000 BURNEIT,STE.140,OONCO�e Ivo- 569462 Phone415-682-158 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT DESTRUCTION `i PUMP INSTALLATION .C, SYSTEM REPAIR i2 OTHER `$ MONITORING WELLS DISTANCE TO NEAREST: SEPTIC TANK 1 mile SEWER LINES 20# _ DISPOSAL FLD.1 mile PROP. LINE _IBD! FOUNDATION 50' AGRICULTURE WELL Q.5 Ti OTHER WELL 1 mile PITS/SUMPS 0.5 miles INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial © Open Bottom G Manteca Dia. of Well Excavation 1 0Tr— pia. of Well Casing 411 C, Domestic/Private CXGravel Pack Ix Tracy Type of Casing,KHED 40,PVC___ _ Specifications i Public f' Other P, Delta Depth of Grout Seal 7' Type of Grout NEAT CEMENT I I Irrigation 255'Approx. Depth i 1 Eastern Surface Seal installed by WEST HAZMAT DRILLING COMPANY Repair Work Done Type of Pump H,P.' State Work Done NSA Veit DestrucsionWell Diameter Searing "hateriat ;:ap 50'I I {� Depth Filler Material !Beiow 50'1 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRrADOITION i DESTRUCTION i tNo septic system permitted if public sewer is b 11 availabielwistin 200 feet.) Installation will serve: Residence Commercial— Other ?Dumber of living units: Number of bedrooms Character of soil to a depth of 3 feet: to r SIA SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Welt Foundation Property Line NSA LEACHING LINE ❑ No, & Length of lines Total length/size FILTER HED Cl Distance to nearest: Well Foundation Property Line .- SFEPAGE PITS I I Depth Size Number NIASUMPS L-1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 licensed 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature 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 comphnsa- tion laws of California." The appli muTitle:must car ail required inspections. Complete drawing on reverse side. Signed i ii1 v�AL'I'ON GEOSCIENCE PROJECT MANAGER Dare: 3-16-90 ��- _ F EP NT USE ONLY Application Accepted by Date / Area Pit or Grout Inspection by Date Final Inspection by _ Date Additional Comments: C��1: -,3 _Sf�4'e p�t7e My�S_ 2_21z_r�1oc'tt�. Q(QrC<e' d wis E'�1NQ T �iCy:�U� C Stk 466-6781 CJL Lodi 369-3621 C Manteca 523.7104 0 Tracy 835-6385 Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazalton.Ave„ P.O. Box 2009, Stk., CA 95201 iI FEE INFO AMOUNT DUE AMOUNT REMITTED CA3'FI RECEIVED BY DATE PERMIT'NO. EH 13-24IREV.i 5+ • EH 14-26 /�/��.