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APPLICATION FOR PERMIT I�'ISAN JOAQAIN �7IN COIINTY PUBLIC HEALTH SCES F ENVIRONMENTAL -HEALTH DIVISION ].60]. E. gAZELTON AVE. , PHONE (209)468-3420 1 2 1, 93 P O BOX 2009, STOCKTON, CA 9520I, - 4 IRSS 1 Y&AR FRO D � ENVIRONMENTAL HEALTH (Complete is Triplicate). PERMIT!SERVICESto c crone or sen Application is hmeerde in compliance San Joaquinth County for ty ordinanceNo. d/ond 18�2sand the Rules end eRegu acribed. This application i �. . Joaquin county Public Health Services. +- I 314$ N. NARDING WAY City STOCKTON, C&t size/Acreage Job Address (209) � 2� Hers Name PETER WALI ACE 19431 N. DEVR I ES RD r,t ODI, OA Phone l U J Ow IT�^Z�,GERALD T , (916Y,-638727 �p RANCHO CORDOVA, CA License No.554979 ---Phone ContractorWEST HAZMAT DRILLING Address TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service.Well Q PUMP INSTALLATION ❑ SYSTEM REPAIR 13OTHER ❑ Monitoring"'We11 ' ti SEWER LINES DISPOSAL FLD. POOP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing C1 Industrial v ETD pen Bottom C3 Manteca Dia. of Well Excavation G Specifications Type of Casing C] Oomesticl Private ❑ Gravel Pack ❑ Tracy Type of Grout�+,r I'1 Public Other n Delta Depth of Grout Seal I I Irrigation S-01 Approx, Depth I 1 Eastern. . Surface Seal instailad S of Pump H•P State Work Done _ Repair Work Dane U Type Z�l Sealing Material i Depth Well Destruction ❑ Well Diameter/ Fi11er Material i Depth y -7,>7;S , Depth ro 5 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADOITiON t S DESTRUCTION 1.1 iNootl septic able cyst m emitted if public saver is eet.I Installation will serve: Residence_ Commercial Other .� Number of living units: Number of bedrooms Water table depth I Character of soil to a depth of 3 lest: Ca ,SEPTIC TANK. ❑ TypelMfg pacity_ No. Compartments Y Method of Disposal PKG. TREATMENT PLT.© � - Distance to nearest:+j- Well Foundation Property Line Total length/size LEACHING LINE ❑ No. 3 Length of lines FILTER BED ❑ Distance to nearest:N Well Foundation Property Line SEEPAGE PITS I I Depth - Size Number SUMPS Ll 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, slate'laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I 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 must call for all required in i omplete drawing on reverse side. Signed Title�� FOR-WEST Hama DRILLINCbate: �- OCTOBER, 93 g FOR DEPARTMENT USE ONLY fApplication Accepted by Date Area /p— - 7 31 . � Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return ail copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 3:50 1 FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE. AERMiT N0,a J✓V lNfO _ U� EM 13-24 1REV.°,M 51 c`S , /� I7 f0-(zsl3 3�! EM 14.26 _ a'�