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.s :. � . ` R APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONNIENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 XPIRES 1 YEAR FROM DAT ED 7r (Complete in Triplicate) Application is hereby made to San Joaquin ounty for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address MadrugaeRoad at Guthmiller Rd. Parcel 0, Book 12, Pa v 52, San Joaquin Cto.,,%�rds ,, APN 241-41-26 t Section 243 T.2S.,R.6E Owner's Namj�aiter and Joanna Keeney Address 1866 Highland Oaks, Arcadia, CA Phone Contractor Earthtec, Ltd. Address 1834 Vernon Street #7 Rosevil�ense No. Phone 408595 phone 916 969 522 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR E7 ?THER h0 Monitoring Well L� bar DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES 601+ DISPOSAL FLO.NR eOtecpROP.'LJAE 40 FOUNDATION 4001+ AGRICULTURE WELL -NL/—AOTHER WELL-ALA— PITS/SUMPS NLA— INTENDED /aINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION 1( T L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ['I Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing_ Specifications I'] Public IN Other Boring 11 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 ❑ Well Diameter Sealing Material & Depth Portland Cement Grout Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is available within 20o feet.I 1 Installation will serve: Residence_ Commercial* Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. CPAIIVtM XNT -N PKG. TREATMENT PLT. 1:1 Met f,, IyI� Distance to nearest: Well Foundation Property Linle'"'ff (� DEC 15 im LEACHING LINE ❑ No. & Length of lines Total length/s' FILTER BED Cl Distance to nearest: Well Foundation ProrREBL*HFAUHISERVICES ENVIR SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS .❑..-Y _ _ .. - - �-,.,� •. _ �� - -- 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: "E 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." til The applicant must �call for II require inspections. Complete drawing on reverse side. � Signed `-'�C Title: Principal Consultant Date: 12/09/92 0 F R PARTMENT USE ONLY , l Application Accepted by Date ea 112 r Pit or Grout Inspection by Date Final Inspection by_ Dattr� Additional Comments: t Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY pA PERMIT N0. . EH r3-2 REV.rix 57 P / / F/z /f EH 141 C i K