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APPLIC T-T ON SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is 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. 54.9 and 1$62 and the Rules and Regulations of-San Joaquin County Public Health Services. Job Address _ 1469_East Hammer Lane City Stt)Ckton _ _ Lot Size/Acreage Owner's Name BP 0 i 1 Company address z955 W41 st Street Phone (206 251-0736 Building 13, Suite N, Renton, Washington, 98005 Contractor Geo-Environmental Address P.O. BOX 3525, Yuba C i Jycense No. 676923 Phone 04 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION 0 Out of Service Weil Cl Soil Borings PUMP INSTALLATION ❑ SYSTEM REPAIR 0811 5O i 1 BorgRJR IN Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public IN Other [A Delta Depth of Grout Seat Type of Grout I I Irrigation _Approx..Depth I I Eastern Surface Saul Installed by a— Reaeir Work Done LJ. Type of Pump H.P. ' State Work Done 1 Well Destruction O Well Diameter Sealing Material Depth Depth Filler Material & Depth Neat cement and bentgn i to ( ' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is NA available within 200 feet.) . Installation will serve:i Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED NA ❑ Distance to nearest: Well Foundation ° Property Line SEEPAGE PITS 11 Depth Size Number SUMPS NA Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that ,he 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 shalt 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicantst call for ail required i pectlons. Complete drawing on reverse side. Signed Title: Senior Project Manager Dater 12/09/94 FOR DEPARTMENT USE ONLY. (/ Application Accepted by Date ,l Area �•v1 Pit or Grout Inspection by Date Final Inspection by Date J Additional Comments. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �✓ ' b jf 445 N San Joaquin, P O Box 2009,,Stkn, CA 95201 FEE 11 .AMOUNT DUE AMOUNT REMITTEDCK H RECEIVED BY GATE PERMIT;NO. INFO . tH ]-24(REV.1xSl V � P/ �•LIL EH 1 / �