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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 � N EXPIRES 1 YEAR FROM DAT �v/ 01 BERMIT _ I O „E ISSUED (Complete in Triplicate) p��Av/�,Vjjr,�F� s� �1�p Application is hereby made'to San Joaquin Cor4 unty for a permit to construct and/or install the work/1SwF � s� bed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules an�'tit*/of San Joaquin County Public Health Services. Job Address 4907 East Water) City_Ctpakt.., Lot Size/Acr(age 09) Owner's Name Ms . Carmelita Cozad Address 4907 East Waterloo Road Phone — 931-3098 2823 as M❑❑rile St , Stockton (209) Contractor Spectrum Address S oct0II License No. 512268 hone 465-8712 TYPE OF WELL/PLJMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. A i1 goring FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom I Manteca Dia. of Well Excavation—$" Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing J Specifications N A — .. C1 Public ill Other n Delta Depth of Grout S _t�� Type of Grout R nu f,n n i tom/ I 1 Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by N Z'AUl, 5. Repair Work Done U Type of Pump H.P, State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 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 ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No, & Length of lines Total length/sire �+ FILTER BED ❑ Distance to nearest: Well Foundation Property Line { SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line N DISPOSAL PONDS ❑ r 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 0 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 O 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." The applicant must call for all require tnspectlons. Complete drawing on reverse side. Signed X Title: Principal pate: 11/5/90 Peter Alm in e r� FO DEPARTMENT USE ONLY a ��? Application Accepted by ..._ __ Date `D res 1133 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments.- Applicant omments:Applicant — Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services i 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH a EH _T t3-21 IREV. /x 61 �b7 0,0 EH 24.20 (/