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APPLICATION FOR PERMIT a SAN JOAQUIN COUNTY PUBLIC HEALTiJ URVICES l ENVIRONMENTAL HEALTH D I V I S IbN P O BOX 2009, STOCKTON, 1,CA 95201 (209) 46834-4-7,j7'4;L-.0 t PTJW1.1s M DATE ISSUED (Complete in Triplileate) Application is hereby de to San Joaquin County for a Permit to construct and/o� mar 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. 3128 W. Benjamin Holt Drive, Stocktonj,CA a J 1 / Job Address / City i Lot Size/Acreage UV -157__ I Owner's Name Exxon Company USA Address _1200Smi fb _13 t,„ gt,; +.e 2_7?6Phone 71 3 Z696-71 ' ins Houston, M 77002 Conlraclor' Address Lit'ense No._=,1_9.4-243._Phone 5 6 TYPE OF WELL/PUMP: NEW WELL ❑ "I" --�IWELC REPLAC MENT 0 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I! DISPOSAL FLD. PROP. LINE !fir �M FOUNDATION AGRICULTURE WELL I OTHER WELLjz2r PITS/SUMPS O� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U ,i n industrial 0 Open Bottom ❑ Manteca Dia. o Well Excavation.- D�a. of Well Casing 7 VC_ �, p + I ci'sl fF ev Q_$:c p S, i�' o .Domenic/Private Gravel Pack ❑ Trac Type df Casing 5 cilications U 8f Y Yp g � � kM Public I:1 Other . ❑ Delta Depth of Grout Seal /O r Type o"rout. M IrriUation —Approx. Depth ❑ Eastern Surface Soul Installed by, I Repair Work Done U Type of Pump H.P. Stale worDane Well Destruction ❑ Well Diameter Sealing Material i Depth' Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION n REPAIR/ADDITION 0 DESTRUCTION C1 (No septic system permitted if public sewer is -available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living unite Number of bedrooms Character of soil to a depth of 3 feet: II Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments E PKG. TREATMENT PLT. C) i1 I Method of Disposal [ Distance to nearest: Well Foundation it Property Line .I� i LEACHING LINE Cl No. 8 Length of lines I.Total length/size s FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size l Number SUMPS LI Distance to nearest: Well Foundation li. I Property Line DISPOSAL PONDS ❑ k f: I hereby certify that I have prepared this application and that the work will be done in accordancewith San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County F Home owner or licensed agent's signature certifies the following: "I certify that in the periorinance of the work for which this permit is issued. I shell not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 workmen's compensa- tion laws of California." The applica must call for all required inspections. Complete drawing on reverse side. I i r � C (� rSigned ' Ditto.. f / �!i I �411`0 DEPARTMENT USE ONLY / c,,CI� Application Accepted by i� Date �-13� Area �� Pit or Grout inspection by to Final Inspection by .h Data l d I Additional Comments: � �� l __-- Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2000, STOCKTON, CA 85201 •I ,F FEE e INFO AMOUNT DUE AMOUNT REWTTED CASH RECEIVED BY$I DATE � PE EK 211REV.i,Rer A,