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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1 YEAR FROM D (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 made in cot nuance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 10261 WATERLOO R D . City S T O C K T 0 N Lot Size/Acreage Owner's Name GEORGE & JANE GOVEIAAddress 10261 WATERLOO RD. Phone 931 -3558 Contractor HENNINGS BROS . Address 3525 PELANDA-L�E AVE . License Ivo. 290813 Phone 545- 1185 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION out of Service Well t ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER 0 Monitoring Well i ❑ DISTANCE TO NEAREST: SEPTIC TANK 1001 SEWER LINES 100 I DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r L1 Industrial ❑ Open Bottom 0 Manteca "'Dia. of Welt Excavation Dia. of Well Casing 611 IX ` ' Domestic/Private L�(Gravel Pack C7 Tracy Type of Casing PVC Specifications BENTONITE N-11'1 Public C1Other, 100 , 0 0� P Delta Depth of Grout Seal r Type of Grout I I Irritation s79:5Aoprox. Depth I I Eastern Surface Seul installed by H E N N I N GS BROS. DRILLING CO . Q Repair Work Done 0 Type of Pump H.P. "'� " Vte Work Donr `r Well Destruction Well Diameter Sealing Material & Depth, I Depth / a Filler Material & Depth- 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 17 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 Not Compartments �f PKG. TREATMENT PLT. ❑ ,. _ _Method of Disposal ! Distance to nearest: Well Foundation Property Line s s LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line r f SEEPAGE PITS 11 Depth Size Number SUMPS L1 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 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." 4 The applicant must call for all- quired-inspections. Complete drawing on reverse side. ;- Signed X__ "�'T / �+tt. Title: I2 A njAV— Date: AUG. 18 , 1992 FOR DEPARTMENT E ONLY # Application Accepted byDate _Z Area �// ® 9 Pit o Grriu Inspection by �Date�' Final Inspection by Date Additional Comments: d / �g� /PC 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 IFF NTD MOUNT REMITTED CASH RECEIVE BY DATE PERMIT'N0. a EH 13-24 IREV-i/x 5! t yy�ty pa EH 94.28 a