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APPLICATION FOR PERMIT �T ;ilt l y AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HTsATTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 OCT 12 1993 P O BOIL 2009, STOCKTON, CA 95201 PERMIT E%PIR ENVIRONMENTAL HEALTH t$ �MM .,.X �� FRO}! DATE � PERMIT/SERVICES (Complete in Triplicate) Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of Sam Joaquin County Public Health Services. City STOCKTON Job Address �^�[1Q V fN i , �,g SING WAY t Size/Acreage li Owner's Name PETER WALLACE 8431 N. DEVRIES RD, SDI C4 Phone (209) 333 25M TI GERALD Tr, ] ContrattorWEST HAZMAT DRILLING Address RA�cm ORDOVA16 License N0.554979 Phone(916) 638]' 2 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z�� O Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Ok Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingP1 C, Specifications ('I PublicV-1"Approx. her In Delta Depth of Grout Seal 6 Type of Grout I I Irrigation Depth I I Eastern Surface Seal Installed by Repair Work Done D Type of Pump M.P. th State Work Done_ .Well Destruction O Well Dismetelr tl lfau al i C Depth to5 Filler Material i Depth 5 An 4C.3" TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) (� 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.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sir Number SUMPS L} Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS 0 1 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, I shall not employ any person in such manner as to become subject to workman's compensation Laws of Califomia.” Contractors hiring or sub-contracting signature certifies the following: "t certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must cad for all required ' ti omplete drawing on reverse side. Signed Titled EOR WEST HAZMAT OR I LII NCbate: 11 OCTOBER, 93 FOR DEPARTMENT USE ONLY / Application Accepted by Date �L e7- ga� Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, E?svironmental Health Permit/Services 1601 E. Raselton Ave., P 0 Box 2009, Stockton, CA 95201 350 CK INFO FEE AMOUNT DUE AMOUNT RREMiTTEo H RECEIVED BY DATEg PERMIT /N0. EH 14.2<tREV.iinsi �+ (. 1/12f1 �a-1;-4 -3 l EH u•20