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APPLICATION FOR PERMIT _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DI 1601 E. HAZELTON AVE. , PEON 68-3420 - P O BOX 2009, STOCBTONPERMIT � 6t'�- 3 EXPIRES Y FR (Complete in TripTi g �7 Application is hereby made to San Joaquin County for a permit to construe �y o��qr,n'sta the work herein Jeacrlbed 3 application is made in compliance with Sen Joaquin County Ordinance No. 5 1titli TT and the Ruies and Arnr]n� t� 1 an Joaquin County Fnb110 Health Services. ill {� �` Job Address 28494 NICHOLS ROAD _ City G _ pot Size/Acreage APN 005-080-013 Owner's Name EVERED J. MASON Address 28499 NIC0LS ROAD, GALT, CA 95632 _ Phone (209) 745-2565 Contractor EARTHTEC, LTD. Address 1830 VERNON ST i'7, ROSEVILLE, LG(hnse No. C57-408595 phone ( 6)786-5262 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION CI Cut of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Z Monitoring Well Ll DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES N/A DISPOSAL FLO. N/A ppiAL BOfiING FOUNDATION _ WA AGRICULTURE WELL N/A OTHER WELL N/A PITS/SUMPS N/A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation. Dia. of Well Casing r I Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_.__ Speuficauons I'I Public Ill Omer fl Delta Depth of Grout Seal Type of Grout I Inipatan — Apple., Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump It.P. ._ State Work Done_ Well Destruction 10 IAWKOiarrow pre Sesliug llaterial s Depth CEMENT GROUT TOTAL DEPTH BORING Depth cnr Filler Material a Dept TYPE OF SEPTIC WORK-, NEW INSTALLATION I I I tPAIR/ADCITION 1 DEST T I 1 (No esprit system Permitted if public sewer is ",evadable within 200 1 Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character, of still to a depth of 3 feet: k ! Water table depth SEPTIC TANK ❑ Type/Mfg No. Compartments PKG. TREATMENT PLT.L) Method of Disposal Distance to nearest: Well Foundation_ �Property Line o LEACHING LINE ❑ No. & Length of lines _ 4ZBraf length/arse FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest. Well Foundation_ Property Line DISPOSAL PONDS ❑ 1 hereby sonify [hit I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state laws, and rules and roguenon, of the Sen Joaooin County Home owner or licensed agent's signature cenilies the following "I certify that in the performance of the work tot which this permit is issued, I shall not employ any person in Such manner as to become subject to workmen's compensation laws of California."Contrecioi s hiring or sub contracting signature canities the following: "I certify War in the performance of the work for which this permit is issued, I shall employ persons subject to workman's comport" tion lows of CNRornia." The applicant mus(cat for all required inspections. Complete drawing on reverse side. Signed � ro�i Title: PRINCIPAL CONSULTANT Date. 02/22/94 IE�2S`� F DEPARTMENT USE ONLY Application Atteptad by kt Due J^ are_. Pit or Grout Inspection by Data Final Inspection by .t Addniomi Comments: Appllcrwt - Returm all copies to: San eE 4 County Public Health Servicicess,, Bavlroomenl Reelih Permit/Services 1601 E. Rainton Ave., P 0 Box 2009. Stockton, CA 5201 U3`�' INfEO AMOUNT DUE �AAMM�(OOU^1NT REMITtED CASH flEC/EI/LVE/D By D�AT]Ey��1 y FN 13]{1aJ9EV ,rn'.i vV 1I.� 7 OY/(� ✓P' / � N Err tab _-