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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 PAYMENT (209) 468-3447 RECEIVED PERMIT EXPIRES 1 YEAR rROM DATE ISSUED (Complete in Triplicate) 0CnrT 0 9 411'90 Application is hereby made,to San Joaquin County for a permit to construct and/or install the vo E117 �iYbcd��`Tl{is application 1s made in conipliance with San Joaquin County Ordinance No. 549 and 1862 and the Hal (I�la'¢'�+if�tri�n�Es�ISaFaS Joaquin County Public Health Services. ENVIRONINIEiAL HEALTH DIVISION Job Address 909 W_ Hammer Ln _ CityStnrktnn Lot Size/Acreage HIJUSOwner's Name EXXON' Cnm�anj7fl-- S A Address 11 _ Bay 441Sr TlnijZtnlj TX Phone( 713)6 6— S; �tts da_ lr 'r Ste . 101 , Scotts Valley Contractor RVAX TPrfinol og- ea1ffdre$s269 Mt . Hermon Rd - _ License No.575 L-2 Phone�—�)4'1,q-71Sl1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ vapoor OTHER M Monitoring Wellobe Q DISTANCE TO NEAREST: SEPTIC TANK 0 f t . SEWER LINES 0 f t . DISPOSAL FLO. O f t PROP. LINE FOUNDATION 9 f t . AGRICULTURE WELL -Q—f-)`.OTHER WELL PITS/SUMPS 0---f t . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �7 k1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O A c t 5;U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S e e A t t a r h P d , Specifications M Public {j{7 Other ❑ Delta Depth of Grout Seal Type of Grout U Irrigation 1-4-Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION Ll DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) `d1 Installation will serve: 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 ❑ No. d Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth _Size_ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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, 1 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 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. tion laws of California." The applicant I call f 11 requuiMired ins P cctions. Complete drawing onreverseside. SignedTitle: /<JL,ory Date: 2 FOR DEPARTMENT USE ONLY G' / Application Accepted by t7 Vc Datey� �3�� Ares 'y15 Pit or Grout Inspection by U Date Final Inspection by � Date r�dJ Additional Comments: _ Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ' 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13-24 IeEv.I/A$) 7Z7 EH:sae ��l,