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k I AoPLIC'VP1 ON SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is 'hereby made to Sen 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Jab Address nvv 146 East Hammer Lane City Stkton_ Lot Size/Acreage r BP Oil Company Address 2955 W41 st Street Phone (206 251-0736 Owner's Name Building 13 , Suite N, Renton, Washington, 98005 Contractor Geo-Env i roam_ enta 1 Address P.O. Box 9 Yuba C i tycense No, 676923..Phone - 04 TYPE OFWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C} DESTRUCTION LI Out of Service well LI Monitoring well Soul Barings PUMP INSTALLATION ❑ - SYSTEM REPAIR E1811 Soi 1 Borq�R CJ ; DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES � DISPOSAL FLD, PROP. LINE �.._. FOUNDATION AGRICULTURE WELL OTHER WELL P175/SUMPS s INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ Dia. of Well Casing n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications. - ('.l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing__ Type of Grout V1 Public (A Other 04 Delta Depth of Grout Seal I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by "w H.P. State Work Done Repair Work Done U Type of Pump Sealing Material 6 Depth Well Destruction ❑ Well Diameter `s Filler Material ti Depth Neat Cement and Benton i to Depth; TYPE OF SEPTIC WOR NA NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is � Ii available within 200 feet.) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms c� Character of soil to a'depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT.❑ Method o1 Disposal (fv Distance to nearest: Well Foundation Property Line lsx LEACHING LINE El No. & Length of lines Total length/size Pro ert Line I FILTER .BED - NA n Distance to nearest: Well Foundation P Y I_ SEEPAGE PITS 11 Depth Sire Number r: SUMPS NA L! Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 II rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: 111 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 p 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 � f , ` tion laws of California.' .f;• The applican&9)L�st all for all r quired i pections. Complete drawing on reverse side. _th Signed X Title: Senior Project Manager Date: 12/09/94 a FOR DEPARTMENT USE ONLY Area Application Accepted by r �" Date .Date`,, "T Date Final inspection by - Pit,or Grout Inspection by M µ� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 c s r 3 5rty' CK F FEE AMOUNT DUE A NT RE ITT RECEIVED BY DATE PERMIT*NO. ' - INFO CASH -1124 IREV.I/A Sl S° 4.20 - - _