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• APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVS�g SNE (2095201-34`20 P O BOR 2009, EXPIRES 1 YEAR FROM DATE iS5[LED (Complete lD Tr25 1pllcate) rmlt to construct asndo1862 and thethe Rulea and Regulatlonsdescribed of Sans Application is hereby made,Lo Sen Joaquin County for a county application is made in compliance with San Joaquin County Ordinance No. 5 9 Josquin County Public Health Services. r of.Cotnmerce St. and Hazelton Ave. City Stockton Lot sir`/acreage � Job AddressCorneCA Phone (415) 972-1116 Pacific Gas & Electric Address One California St. , S.F. 94106 Owner's Name 283326 Phone(916) 662-28 9 1202 Kentucky, Woodland, L rise No. Developme_ nt Corp Address DESTRUCTION ❑ Out nn Service well ❑ Contractor WELL REPLACEMENT ❑ 2Monitoring well ME OTHER ❑ NEW WELL C3 TYPE OF P' SYSTEM REPAIR CI PROP. LINE -- PUMP INSTALLATION ❑ vt 50 feet DISPOSAL FLD. SEWER LINES OTHER WELL PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL FOUNDATION MW-12) PROBLEM AREA CONSTRUCTION SPECIFICATIONS (MW-11, 4 inche INTENDED� SE TYPE�� 12 inches Dia. of Wells At ached ❑ open Bottom ❑ Manteca Dia. of Well Eaca PVC Specifications ❑ Industrial O Tracy Type of Casing (` §Ll Gravel Pack of Grouter-- 1 C.I Domestic/Private n Delta Depth of Groat Seal 45 feet Tye I'I Public I:1 Other Surface Seal Installed by I I Irrigation �-�APMo• Depth I I Eastern State Work Done f P Type of None H.P. +. Repair Work Done C] $esling Material 6 Depth v Well Destruction ❑ Well Diameter Filler Material L Depth rmitted it public sewer is Depth available within 200 feet.) TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I IN optic system Installation will serve: Residence Commercial_ Other Number of living units: _ Number Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Foundation Property Line Distance to nearest: Wl11 Total length/size LEACHING LINE LI No. & Length of lines Foundation Property Line FILTER BED CI Distance to nearest: Well Size �- Number - SEEPAGE PITS 11 Depth Property Line SUMPS LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ oaquin county ordinances, state laws, an I hereby certify that I have prepared this application and tat the work will be done in accordance with San J h rules and regulations of thSan Joaquin County g y Moms owner or licensed agent's si nature certifies the following: 'I cerci} that in the performance o1 the work for which this permit is issued, I signature shall not employ any ion certifies the ollowin such cart manner that n the performance subject of the work afor which this sperm its issued, I shall employpersons lsub sring ubject to workmaSub-contracting s compensa tion laws of California." The applicant m�t call for all requir/el�nspections. Complete drawing on reverse side. y .r 1 Q� 4� Title: Date: l.. Signed X ___!—.STS--•I.SI SZ Y4^T -T ' ^ FOR DEPARTMEN USE ONLY { l .I 11-xf� Date Z Area Application Accepted by r Pit or Grout Inspection by Date Q '/ Final Inspection by Additional Comments: Applicant - Return all copies to: Services, Healthin County Public Ll Etvirome ontal Health Persit/Services e �t'�I/ 1601 E. Hazelton Ave.. P 20091 Stockton, CA 95201 CK a RECEIVED BY DATE PERMIT NO. FEE AMOUNT DUE - AMOUNT REMITTED INFO Em 13-24 A-2t IREv vx En u.la