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APPLICATION FOR PERMIT '' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DI 1601' E. HAZELTON AVE. , PHON � 6$-3420 P O- BOX 2009, STOCgTON PEMIT EXP RES 1 YEAR FR0 'D it {Complete in Tripl IUPI fa Application is hereby made to San Joaquin County for a permit to construe Is ta the vork herein described( 7 application is made in coapliance with San Joaquin County Ordinance No. 5 , ( and the Rules and Re an Joaquin County Public Health Services. ' Job Address 28499 NICHOLS ROAD City G Lot Size/Acreage APN 005-080-013 Owner's Name EVERED J. MASON Address 28499 NICNOLS ROAD, GALT, CA 95632 Phone (209) 745-2355 Contractor EARTHTEC, LTD. Address 1830 VERNON ST �7, ROSE=VILLE, Lgt°'ense No. C57-408595 Phone (916)786-5262 TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER )7 Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK N/A SEWER LINES N/A DISPOSAL FLD. N/A PR6TMMICAL BORING FOUNDATION N/A AGRICULTURE WELL N/A OTHER WELL N/A PITS/SUMPS N/A INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial 0.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications I'i Public -1-1 Other . 1l Delta Depth of Grout Seal Type of Grout I I Irrigation __,__Approx. Depth 11 Eastern Surface Seat Installed by Repair Work Done U Type of Pump H.P. State Work Done __ F Well Destruction 91 kt> XDiameter Ar! sealing Material i Depth CEMENT GROUT TOTAL DEPTH BORING Depth gog Filler Material fl Dept i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DEST 7 I 1 (No septic sgslem permitted if public sewer is '.1vivailable"within 200 feel.i Installation will serve: Residence_ Commercial_ Other r� G Number of living units: Number of bedrooms r c.ty Character of soil to a depth of 3 feet: ° CP " Water table depth SEPTIC TANK O Type/Mfg Cap44W , L i' No. Compartments PKG. TREATMENT PLT.❑ _; .�F \�. Method of Disposal Distance to nearest: Well Foundation Y' Property Line [� LEACHING LINE 0 Nn. & Length of lines �.}4ital length/size FILTER BED 1=1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI 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, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any peraon in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contractirig signature certifies the following: "1 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 inspections. Complete drawing on reverse side. i Signed Title: PRINCIPAL CONSULTANT Date: 02/22/94 F DEPARTMENT USE ONLY Application Accepted by #ZfDate Area Pit or Grout Inspection by .Date Final Inspection by ' ateA Additional Comments: Applicant - lieturn-&11 copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 1/ FEE. AMOUNT DUE AMOUNT REMITTED INFO CASH RECEIVED BY" DATE PERMIT'NO.