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" APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ' OL PERMIT NOXP RES 1 YERFRMDATE ISS � (Complete in Triplicate) A�O 4f`, Jia„ Applica is hereby made.to San Joaquin County for a permit to construct and/or install the work'14 >a ,fbed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulesan "ti p�l of San Joaquin County Public Health Services. Job Address 4907 East Waterloo Road City S t•n r•k t nxL Lot Size/Acreage Owner's Name Ms , Carmelita Cozad Address 4907 East Waterloo Road , ph(e09 )931-3098 2823 asM rtle St , Stockton 209} Connector Spectrum Address Stoc to�i License No. 512268 hone 465-8712 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C) Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER Q0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. Ail i 1 Borin6 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 811 Dia. of Well Casing —X lam_ F.1 Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing / Specifications.N4A I'1 Public El Other [I Delta Depth of Grout S _ Type of Grout Ra n t n n i I I Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by N/A--A C em ant Repair Work Done U Type of Pump H.P. State Work Done_ Weil Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITION I i DESTRUCTION I I INo septic system permitted if 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, 11 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No, B Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I i Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 11 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 subcontracting 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X— Title: Principal Date: 11/5/90 Peter Alm In er['�Q��4�,, F�O DEPARTMENT USE ONLY AFol Application Accepted by �"`"'`""'c—! �u Date res "Z Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 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 FEE INFO �JAMMOUNT DUE AMOUNT REMITTED CASH CK if RECEIVED By DATE PERMI7'NO. . EM 13.24[REV.,,nst 7ti f CIOt\F 04 �ITO EH A-25 (/ L/