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APPLICATION FOR PERMIT SAN'aJOAQUIN COUNTY PUBLIC HEALTH S�iVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 REMIT EXPIRES 1 YEAR_f ROM ,SATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install, the work herein described. This application is Mede 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 4907 East Waterloo Road (Hwy. 88 city Stockton Lot Size/Acreage 9.5 owner's Name Carmel ita Cozad Address 4907 East Waterloo Road Phons209/931-3023 3233 Fitzgerald Street Contractor West HazMat Dri i l int Address Rancho Cordova License No.C57-554979 Phone 216/638-72 TYPE OF WELL/PUMP: NEW WELL 2 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cji 3 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 55! SEWER LINES NIA DISPOSAL FL0.40MW-3 PROP. LINE €'_/A MW—I FOUNDATION --L5-.L- AGRICULTURE WELL N/A OTHER WELL 130 t PITS/SUMPS N/A MW-2 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11W-3 U Industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation a Inch Dia. of Well Casing 2 inch U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing PVC Specifications 13 Public M Other Sand Cl Delta Depth of Grout Seal 50 t Type of GroutPo rtl and&Ben n i M Imitation 70Approx. Depth ❑ Eastern Surface Seal Installed by HLA & 4-lest HazMat Repair Work Dons U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material Ii Depth Cement & Ben ion 7 e X Monitoring Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 13 REPAIR/ADDITION M DESTRUCTION G (No septic system permitted if public $swat is available within 200 lost.) Installation will Serve: Residence_ Commercial_ Othet Number of living units: Number of bedrooms 1.1 Character of SOH to a depth of 3 feet: SAN JOAQUEN COUNTYgffilyrtirrients �LTH SERVICES SEPTIC TANK D Type/Mfg Capsci&NVIRON 'fvMIUM PKG. TREATMENT PLT, o SILECIAC-d"PE i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/sits FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sirs Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS O I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and rules end 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 cenifiss the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- tion laws of California," The applicant must tali for all required Inys, ions. Complete drawing on reverse side. Signed Tette: Geologist Date: 6/14/91 Herb Steffe Harding Lawson Associates FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date� Final Inspection by Dsta 273 / Additional Comments: {( Applicant - Return all Copies to: SAN JOAQUIN COUNTY PUBLI HRA SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 446 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 86201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO CASH. OATE PERMIT NO. tH,st.raty. S1 <:IfC'l F •'� i