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_ f h tri i,cx rj"" 0 4/9 1 1 '� : 1 E i x } APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION P O Biz% 2009, STOUKTON} CA 95301 (209) 46g- 710 FIT! (Complete In Triplicate) Applicatiah is hereby emde,to Ran Joaquin County for a permit to construct and/or install the w6rk hereir,'dt+ecribad� !�ThFa applicrtion is Stade oa� in cliarnca with Ban Joaquin,County Orriinanca No. 549 and 1862 and the Mules and Regulations of; Ban Joaquin Coultty Public Health Services. Job AddFOie ..312. �`��Y,�-MiIIQ7,#, n,i_vr. _.,... . City,..5.t,nckt-nn _ Lot 816,/ACrdaga -14f1 _x_ Ina l..f.t_-- EXXON Co, USA 200 Smit? 5t/�� ite_2726 Owner's Name Address ota�ton, . Phone 71 - Engineering-Science 600 Bancroft, Berkeley 509158 No. 509158 Prone 415-548'� Contractor .�� _Address792 TYPE—OF WELLIPUMP: NEW WELL Q WELL REPLACEMENT C] DESTRUCTION Q Out of 9srrice sell PUMP INSTALLATION CJ. SYSTEM REPAIR O OTHER )Z Monitoring Weil �'pFY- far,y7 ' DISTANCE TO Nt_AR1:5T: f>(:PTlC TANK NIA SEWER UNE5 „��•'ai!�� DISPQ$AL FLD, ^l � PROP, LINE li fir• i POUNDATION 13 F'�• AGRICULTURE WELL .2 Doer:* OTHER WELL r PIT$t$t1MPS L�LA .� 1 f.7 lndunrlef p Open Bottom - _ Q Manteca Die, of Welt Excavation . ..— I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N n i Dia, of Well Casing t 0 Romteliciptivele XGravel Pack 0 Tracy Type of Caeing, Pyc-.____— Specificalions TVP�A .0 p,ihlic l:I Other X Botts Depth of Grout Seal Type of (iroui /.d"ry 5a/(ifrux G IrNgatiun 4d F7.Approx, Depth U EOstorn Surface Soul Insiotied by k Repair Work Done L7 Type of Pump — H.P. $tete Work Dona :r Will Destruction D Well Diameter M 8atlirt6 Material 46 Depth ! Depth _ Filler Material A Depth TYPE OF SEPTIC WgAK; NEW INSTALLATION Q REPAIRIAODITION M 09STAMION G Wo septic systam parmitled if public sewer I 4 tvsileble within 200 fast.) !� installation will serve: Residence_ Commercial— Other Number of living unite: _ Number of bedropml Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfy Capacity _ No. Compartments if PKG. TAf„ATMENT PLT. 0 Method of Disposal 0101ense 10 neereet: Well Foundation_ Propany Line LEACHING LINE C1 No. d Length of lines Tale1 length/she 4 FILTER BED I Dittance to nearest: Well Foundation _ Pfopbrly Line � f SEEPAQE PITS 1 i Depth Sire _ -- Numb SUMPS Ll Distanca to nearest: Well r foundation - 4perty f.fne j DISPOSAL PONDS Cl I hereby certify that I have prepared Ih)s application and that the work will be done kr accordance with.San Joaquin county ordinenCes, state law=, and rubs Ond ragulelions of the San Josgvin County Home owner or liCOnied egint's 0ionsture Certifies the following: "I cortify that In the porlormonce of the work for which this permit is issued, I shall nor -employ any parson In such manner as to becorna subject to workmen's compontetion laws of California,”Contractor': hiring or sub-contracting algnature 1 sonifies the following,"I Certify that in the performance of the work for which this permit Is issued, I shell employ persona subieet to workman's compens0- tion laws or Cetlfornle," The appl4cant mu oil 1 4 toq Ired Inspections, Complete drawing on reverse Olde. SiGnod Title I /�Jor� D� Date: r FOFi DEPARTMENT USE ONLY / Application Acts"' by sate _ r< 9� I Area I Pit or Grout Inspeellon b Data I ""�2 S- y T.��I. .Final Inspection dY `� =`� Date �� Additions! Comments: Applicant - Return all copies 'tot SAN JOAQUIN COUNTY PUBLIC HEALTH BINVICES - ENVIkONLENTAL HEALTH DIVISION PZRMIT/SERVICSp 445 N 9AN JOAQUIN, P 0 BOE 2000, BTUCKTON, CA .95201 FEE r r1tFt7 AMOUNT 13u; AMOUNT IiEMiTTED CASH HECEIVED aY DATE REAMI1'N0. A,21 E>i I�;�irEY,tfav pr