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APPLICATION FOR PERMIT HEALTH SAN JOA UIN COUNTY PUBLIC R @ T SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 s P O BOX 2009 STOCKTON CA .95201 -Ni,j SIT EXPIRES I YEAR FROM DAIR ISSUED ' R (Complete in _Triplicate) `�iti 117 r'r!'I f �ti;AL w rF.4�H . Application is hereby made to San Joaquin Count for County permit to construct and/or install the �r6r��li�rk!]3:.alegG�e�• This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and;Regul.ations of San, Joaquin County Public Health Services. Job Address Cityt eTs— Lot Size/Acreage Owner's Name Ultramar Inc . Address 525 West 1'hira StreetHanforf,one'20 — A-575662 _ 408-438-7511 _ Contractor V A X T@r__h n Q IQ� Address269 Mountrplone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION "Out of Service'Well ❑ a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring,Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE f FOUNDATION AGRICULTURE WELL OTHER WELL—"PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS /vr 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation akia.'of Well Casing 1 12 in h Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing *,Specifications FI Publics ft Other [%1W C k t O n Depth of Grout Seal Type of Grout r y V3 l rf'9qIr a C t i O n—Approx. Depth I I Eastern Surface Seal installed by Repair Work Done U Type of.Pump H.P. State Wggfk Done Well Destruction ❑ Well Diameter Sealing Material k Depth c e m C n L (� Depth Filler Material & Depth Vf �i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION'l I INo septic system perr'nitted if public sewer is available within 200 feet.I I installation will serve: Residence. Commercial Other I Number of living units: Number of bedrooms Il Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,Ll Method of Disposal Distance to nearest: Well Foundation Property Line 'I LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I I Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby sonify 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 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of thework for which this permit is issued;:I shall not ,i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring"or sub-contracting signature 1��,, 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- V tion laws of California." The applicant mu or all to re - s tions. Co late drawing on reverse side. air Signed x Title: Date:2 8 March 1991 Owner/ Enine.ering Contractor A FOR DEP R7MENT USE ALY Application Accepted by Date Area' ` Pit or Grout inspection by � ,Date w r Final Inspection y Date r 9 Additional Comments: i Applicant – Return all copies to: San Joaquin County Public Health D Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE CKINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE r; PERMI7•NO. . EH 13-24 1AEV.1/Ast �h EH 11.2E