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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION SAN JOAQUIN COUNTY-PUBLI � IHH MN AVE. , PHONE (209)468-3 �7 /1 QY ENVIP!�NMENTAL HEALTH DITSQ)MOR 2009, STOCKTON, CA 95201 N'v rte �S P 19 SFt,CIAL PEPddiff EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) FLLS� n ��.,,ff /�/ Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein rde�cif9FFed�'I'his application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7647 PACIFIC AVENUE City STOCKTON Lot size/Acreage 16,500 SQ/F'I' Owner's Name THRIFTY OIL CO. Address 10000 LAKEWOOD BLVD DOWNEY CA Phone 213-923-9876 Contractor SB&S NVIRONMENTAL DRddress 3022 W. SANTA ANA FRESWense No. C57560175 Phone 209-227—£I2 TYPE OF W MP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of service Well 1-i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 6a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g Dia. of Well Casing 211 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ PVC Specifications Schedule 40 11 Public fk91her n Delta Depth of Grout Seal Or — 295_ Type of Grout Sand/cement I I Irrigation 55_ Approx. Depth I I Eastern Surface Seal Installed by SB&S ENVIRONMENTAL DRILLING Repair Work Done U Type of Pump H.P. State Work Done — Well Destruction ❑ Well Diameter 2 Sealing Material L Depth Benton i t P ?9 f — 3 1 f Depth Filler Material ii Depth #3 Sand 31 ' — 55' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. b Length of lines Total length/size— FILTER BED 1-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth __ Size _ Number _ SUMPS LI Distance to nearest: Well Foundation Property Line _ 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, 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 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 compensa tion laws of California." The appfica t must cal for all required inspections. Complete drawing on reverse side. Signed X RG 4 321 Title: PRINCIPAL SSB NVIRONMENTAL Date: 13, I941 SULTANTS INC. U OR DEPARTMENT USE ONLY Application Accepted byy / Pit or Grout Inspection by Oate Final Inspection b re' � Additional Comments: S E';;, Applicant - Return all copies to: San Joaquin County Public Health O Services, Environmental Health Permit/Services 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMIT-TEDCASH RECEIVED V DATE Ml7 NO. EH 13 4 FH f2a