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APPLICATION SAN JOAQUIN COUNTY PUBLIC PJNJK V-1 1-5 ENVIRONMENTAL HEALTf 445 N SAN JOAQUIN, PHONEn9J 8-3420 ` P 0 BOX 2009, STOCKTO �� 201 k PERMI T ESP I RE S 1 YEAR FR I S SUED (Complete in Trip ) Application is hereby made,to San Joaquin County for a permit to constr t �oi� i n dbed. This application is made in compliance vith San Joaquin County Ordinance No. 4 ana San Joaquin County Public Health Services. Job Address 11442 East Ada Avenue City Stockton Lot Size/Acreage Amirka Lucca Address 11442 Fast Ada Avenue Stkn Phone - Owner's Name � Contractor Baumbach $ Piazza Address 323 West Elm Street. LCfddense No.RCE19638 Phone (209)368-66 8 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION D SYSTEM REPAIR 0 OTHERO Monitoring Well L7 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 n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications (1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ State Work Done _ Well Destruction O Well Diameter Sealing Material 6 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other PERCOLATION TEST Number of living units: Number of bedrooms MS-93-0012 No. of Holes 3 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number - -_ SUMPS--- —t+° Distance to nearest:-- Welt Foundation-- - Property-Line DISPOSAL PONDS O 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, 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 applic for all re 'ed i ctions. Complete drawing on reverse side. Signed Title: Civil Engineer Date: 12/16/93 FOR DEPARTMENT USE ONLY Application Accepted by Date [7-1 L Area Pit or Grout Inspection by Date Final Inspection by Date 9 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH CK ifRECEIVED BY DATE PERMIT'N0. . EH 13-24IREV.linsi i EH 11.26