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-4; APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f� ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 JUN 17 291- (209) 468-3447 Pjl'iRYIT E%PIRISS ] YEAR PROM- DATE ISM& I-,N!V;R0 NN11Et`1TAL HEALTH (Complete in Triplicate) PE-R 41TISERVICES 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 compliance with San Joaquin County Ordinance No. 549 and.1$62 and,.the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4907 East Waterloo Road AKy. 88 - city Stockton Lot Size/Acreage 9.5 _ __— Owner's Name Carrel ita Cozad Address 4907 East Waterloo Road Phone - 309.3 3233 Fitzgerald Street Contractor west HazMat Drillin Address Rancho Cordova License rro.C57-554979 Phone - ZE TYPE OF WELL/PUMP: NEW WELL 19 WELL REPLACEMENT 0 DESTRUCTION ❑ put of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 3 Monitoring Well 04 DISTANCE TO NEAREST: SEPTIC TANK 55.t SEWER LINES NIA- - DISPOSAL FLD.40MW-3pnop. LINE N/A MW-1 FOUNDATION 65 r AGRICULTURE WELL N/A OTHER WELL 13Q r PITSISUMPS R/A MW-2 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F -3 nIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0 i n C Dia. or Wel! Casing 2 inch U Domestic/Private ❑ Gravel Pack _ ❑ Tracy Type of Casing PVC r Specifications ' M Public X1 Other Sand ❑ Delta Depth of Grout Seal SG Type of GroulPortl and&Bentoni tE G trrigatlon DApprox. Depth ❑ Eastern Surface Seal Inslailed by HLA & West HazMat Repair Worst Done U Type of Pump H.P. State Work Done _ Well Destruction D Well Diameter Sealing Material i Depth Cement & Bentoni te X Monitoring Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEWINSTALLATION f❑ REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is available within 200 feetJ Installation will serve: Residence— Commercial li �rr Number of living units: Number of bedrooms �T,T Y� n�S Writ_*�f'1� ---Q Character of soil to a depth of 3 feet:.. j�•'1Q �e�t Ia.G6�t SEPTIC TANK ❑ Type/Mfg Ce 1 PKG. TREATMENT PLT. 0 SDIA19S H11YUH Distance to nearest: Well Foundation Property Line ,; M .ids: LEACHING LINE 0 No, 8 Length of Eines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Site Number - SUMPS Ll 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not I� 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 Californla." The applicant must call for all required ins tions. Complete drawing on reverse side. Signed X Title: Geologist Date: 6/14/91 Herb Steffe FOR DEPARTMENT USE ONLY Harding Lawson Associates r Application Accepted by _. � r ` ` _ -- _. Data 6 `� Area �3 Pit or Grout Inspection by Date�._ . Final Inspection by Data 3 f Additional Comments: A1.3 - Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES i 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO C CASH . EH 13-ZltREV.,in 51 EM,420 CJ r r