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APPLICATION FOR PERMIT { ) SAN 'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PHONE (209)468-3420 1601 P BOX 200TON AVE. , CA 95201 a P O BOX 2009, ° I: ro g�RhIT E%PIRES 1 YEAR F nnu DATE ISSUE � 'I (Complete in lrlpli ave) r install. work in Application application is Se hereby incompliance withsan Joaquinfor County Ordlrmit nancenNo. 549 andstruct o1862 and theeRules and Regulations dof San' Joaquin County Public Health Services. - 150'X180' 500 East Grantline Road c;,y Tracy Lot Size/Acreage ___---p— Job Address - -r Mobil Oil Corporation Address 3800 W-AlamedarSuite 700,BurbankPhone (818)953-2626 Owner's Name h 1 Contractor W•Hazmat Drilling Address 23953 Saklan Rd* ,HaywardLicense No. 554979 PhonE510)782-87,7 of service Well. U TYPE OF WELL/PUMP: NEW WELL ❑ " ' WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Monitoring Well PUMP INSTALLATION,❑ :' SVSTEZSi;EPAIA ❑ OTHER ❑ , DISTANCE TO NEAREST: SEPTIC TANK .1 mi' SEWER LINES 'DISPOSAL FLO.1 mid .PROP. LINE 10 :f . ml. 'lmi. PITS/SUMPS �•5mi. � . FOUNDATIONAGRICULTUREWELL OTHER WELLv+ r' INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS - - - Err 12— Dia. of Well Casing ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation jl Cl Domestic/Private M Gravel Pack x] Tracy Type of Casing SCH 40 PVC Specifications Neat Cement 1'1 Public f7 Other : fl Delta Depth of Grout Seal Type,of Grouts''" 35' West Hazmat Drilling Company !1 Irrigation _.Approx. Depth 1 I Eastern :Surface Seal Installed by ;k Repair Work Done ❑ Type of Pump ling H.P. State Work Done _ SII /✓� Well Destruction O Well Diameter -�: � _ eaMaterial i Depth'. €i Depth Piller Material L Depth FFA PTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted it public sewer is I� 4 I' available within 200 feet.) J� will serve: Residence_ Commercial--N_ Other - jl living units: , Number of bedroomsli f soil to a depth of 3 feet: r� Water table depth '1 K. ❑ Type/Mfg r �• Capacity No. Compartments {! MENT PLT. ❑ `' - Magd gjQlspp 'I- ATIVI�T� Distance to nearest: 'Well Foundation Property me BECEIV LEACHING LINE ❑ No. & Length of lines Il Total length/si (I' A r' A FILTER BED ❑ Distance to nearest: Well FoundationPro��r q ��H TY � ISEEPAGE PITS �O(Depth Size Numv - SUMPS LlDistance to nearest: Well Foundation PropertyLine "y11I DISPOSAL PONDS ❑ ' 1 hereby certify that I have prepared this application and'that the work will be done in accordance with San Joaquin county ordinances, state laws.1 and rules and regulations of the San Joaquin County 'li :1 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: "1 certify that in the performanceof the work for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws of California." N , The applicti ca for ell re d in Faction. Complete drawing on reverse side. - Senior Geologist 3-25-92 Signed �V'1'.9. 'Title: Date: '�jf. FOR DEPARTMENT USE ONLY I Application Accepted by " ' '" F 9 Dataky/.�L�//��/ 1 Pit or Grout Inspection by Oate ( Final Faction y Date 1�-L—` �'7)! C./xlal//J UNIT Additional Comments: '1 "l i Applicant - Return all copies to: Ban Joaquin County Public Health 6ervlces, Environmental Health Permit/Services U(J 1601 E. Baselton Ave., P 0 Boz 2009, Stockton, CA 95201 i NFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT NO. . ER 13-24(REV.i,e a g e, of 2� �y17YJ 3 .31-9Z 92-D63 ''4 EM:4.M