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f h'0ff 1 ' APPLICATION FOR PERMIT BAN JOAQUIN COUNTY PUBLIC REALTH IBBRVICNS ENVIRONMENTAL HEALTH DIVISION P Q BOX 5009r STOCKT0N, CA 86501 (209) 468-Z*"J� (Complete In Tri,pli.cate)' Appxiratserr !e hereby mads to Sao Jwqutu County for a permit to construct1and/vi install the work herein �etld��tsbdJ 'thirt applic►tioe is atade in Coan�plianoe vi Eh Ban Joaquin,county Ordinance "a. $49 and lids and the huiea and Ae$ulations of Ban dosquin county Publio Health services, Job Address 3128 West appiarnin Hal-t-_Dr.Lye __ _ City Lot Site/Acreage EXXON Co. , USA 200 Smit $St ite," 2726 - -OwnerNam$ Address ton Phone Engineering-Science 600 Bancroft, Berke] .�,C�icE.nse too. 509158 f'ftipn! 415- 4 Conlfaclor-„„,..� Address 8-79 r TYPE OF ELL/PUMP: NEW WELL O WELL REP LAC MENT rl ° DESTRUCTION 0 Out of $ery ce Well PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHIR Monitoring Well 00 F� T^ loan DISTANCI TO NEAREST: SEPTIC TANK NIA SEWER LINES - z ;t �f]ISPOt3AL FLO. PJ 14 PROP, LINE Il frr. � ,1 FOUNDAVON 1 FFT, ARRICULTURE WE_Lt "'10064r"OTHERJWELL-:L .t'� PITS/SUMPS _, LA W fllINTE#rl - - INTENDED U$12 TYPE OF WELL PROBLEM AA_CA CONSTRUCTION 5P;I;CIFfC�ITIONI's $t 0 Open Bottom 0 Montecs pie. of Well excavation --�2 I NS.}ir_ Ott, of Willi Caving , Ll Domestic/Prlyale X(3revel Peck 0 Tracy Type of Citing- DVC.,,, P___ Spacif;eatioro lo Wootl(FOL.Ayd I N public f:I other delta 04plh of grout Sootf_ Type of ( out L 5 &v t1 Ifripatlon 4aT•Apprex, Depth 0 6stern Surfici Sint Iniitlledl � by � Repel►Work bons, V type of Pump H.P. , __-- _�? $w#Work Done Well Destruction a We" Diameter _.. .r�,__. $Riling Hateriai 11 Deptl 11 � depth tiller It'rteriri 1 Depth �� ;I i TYPE OF SEPTIC WORK: NEW tNSTALLATION j0 REPAIR/ADDITION 0 DESTALICTIOR 0 74o sopoc s Hem permitted if public sewer is eveneble within 200 feel.) a tn$talreNon will Serve: neeidenoe — Commercial— Other ` Number of living uniti: Number of bedroom$ Cnpractet of toll to 6 depth of a feet; ,,,,,,..,.,. .._�_ 'r -Water table depth SEPTIC TANK O Type/Mfg capacity No,_ No, Cbmpentronts PKQ. TREATMENT PLT.0 i° Method of Ditpotel Dltnenae to neereelt Well __ Foundation!I Property Lin* it I LEACHING LINE Cl No, A Length bf Ilnas Total Ii1'glh/oke / FILTER BED fl Distinct to nearest: Well I:oundatiorl - Pfopirty Line yy SEEPA06 PITS 11 Depth $11t __�__�_ _ I'Numb .r I SUMPS LI Dletenca to nearest: Well _._ �. Eoundeflon - '______ %fit, party .int DISPOSAL PONDS a I hereby coolly that I hevs ptspared this application And that thb work will be done In iccot4n- a with San Joaquin county ordinsnces. Stitt laws, end rules and Fegul$tlons pf the Ben JoaquM county I� Nome ownaf or fitanted tpent's signelute coniflel the following: "I earthy that In the stertormence of the work for which this permit is l$sued, I$hill nes employ any person In ouch manner as to become subject to worMrnen's compensetibn laws of•CallfornlA," Contractor's hiring or sub-connecting slgnetur$ r certifles the followingi "I certify that in the performance of thi Work for which this plrmh Is Iselued, I jhAll ernptoy pOrooni aubject to workman's comporw- tion laws of Cellfornit," The applicant mu Sill req Iced Inspections. Cornplate drawing on reverie $ids. �? Signed Title: la�r �" 1`�Lt�f Date: FOR DEPAR1'MINT U9E ONLY ' i Appllcetlon Aetipted byDole 9, Area , Il i *� Pet or.Grout Intpeetlan by N - t]ate3 ell FinalInepectltin by_ � Dat ii i Addlslonal Comments: - Applicant - Aetura all copies tet SAN JOAQUIN COUNTY PUPLlC HEALTH 821tyi" ENVIADNYENTAL HEALTH DIVISION PERMIT/SERVICES 445 N BAN JOAQUIN, P 0 BOX 2009, STOCKTaN, Ce 8690E k6 INFFitA' 11 DUE AMOUNT REMtTTF4 CA01 tiH pECEIVEo By DATE PERMIY O rH 'n!1 Ap