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APPLICATION FOR PERMIT SAN JOAQUINICOUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. ; PHONE (209)468-3420 : P O BOX 2009, STOCKTON, CA 95201 r, tl , PERMTT•EXPIRES 1 YEAR FROM DATE ISSUED f' (Complete in Triplicate) f: Application in hereby made,to San Joaquin County,for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.., I Job Address 500 East Grantline Road '' City Tracy Lot Size/Acreage Owners Name Mobil Oil Corporation Address 3800 W. Alameda,Suite #700,Burbaptone (818)953— 626 ! � l Contractor W•Hazmat Drilling Address 23953 Saklan Road,HaywaA§Icense No. 554979 Phone(510)782-877 j TYPE OF WELL/PUMP: .- NEW WELL ❑ li - WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑` PUMP INSTALLATION ❑ iL SYSTEM REPAIR ❑ Soil BOrin@THER 6 Monitoring Well ❑� DISTANCE TO NEAREST: SEPTIC TANK 1'mile SEWER LINES .!rjr ` DISPOSAL FL?i<l ml• PROP. LINE 10, 4 FOUNDATION 50t AGRICULTURE WELL O.5m1. OTHER WELL`lmi• PITS/SUMPS 0_5mi.. INTENDED USE TYPE OF WELL I PROBLEM AREA CONSTRUCTION SPECIFICATIONS Itt x ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -N/A Cl Domestic/Private [X Gravel Pack a Tracy Type of Casing N/A Specifications ('I Public CI Other n Delta) Depth of Grout Seal 10, Type of Grout Neat.Cement) I I Irrigation L02Approx. Depth I I Eastern Surface Seal Installed by N/A I t c I H,p, N/A 'Sta a Work Done rl 1 ring O Repair Work Done U Type of Pump 11 1 Sealing Material a Depth N/A bap rou withneat Well Destruction ❑ Well Diameter ,) I Depth " I; Filler Material 6 Depth NSA Cement. dl• TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOtTION I I DESTRUCTION I I (No septic system permitted if public sewer is 1, li n available within 200 feet.) '1 Installation will serve: Residence— Commercial _� Other - �� Number of living units: _ Number of bedrooms F NCharacter of will to a depth of 3 feet: y, li Water table depth f{• SEPTIC TANK. ❑ Type/Mfg II Capacity No. Compartments U PKG. TREATMENT PLT. ❑ P Method of Disposal C r Distance to nearest: Well Foundation Property Line LEACHING LINE LINE ❑ No. 6 Length of lines II ,Total length/siz Nle FILTER BED ❑ Distance to nearest: Well Foundation Propert �Line LL ) 2 s iS92 SEEPAGE PITS I I Depth r Size Number p - � C 4 rv� SUMPS LI Distance to nearest: Well foundation P c�,�WI Aj TN cFnvICES ��. r} ENVIRONMENTAL HEALTH DIVICI DISPOSAL PONDS ❑ :. � p 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 County II I — 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 workmen's compensation laws of California."Contractors 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 compensa- tion laws of California." The epplica st all for all Isicuired inspections. Complete drawing on reverse side. - q ,t- Signed I Title: Senior Geologist Date: 3-25-92 l 'FOR DEPARTMENT USE ONLYF - 2 Application Accepted by { - Date 3-51"72— Area Pit or Grout Inspection by Date .3. gJvFinsl Inspection by "ViZODDate Additional Comments: Z Applicant - Return copies to: 3m oaquia Countyic Health rl Services, Etvironmental Health Permit/Service- 1601 E. Hazelton Ave., P 0 Boz 2009, Stockton, CA 95201 [, FEE J INFO AMOUNT DUE AMOUNT REMITTED CK F1 RECEIVED BY DATE PERM17'NO. . EN 13.24(REV.1/.!r j, OCA ' O9.GZ� Z23 I I3 EN^xae