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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 F Np RES I YEAR FR AT N�1,p (Complete in Triplicate) p •��V 6 E� M4 !9 Application is hereby made,to San Joaquin County for a permit to construct and/or installthe work/ s 1Grt' 'd� Ded. This . 549 and 1662 and the Rules an�g� Rf San application in made in compliance vith San Joaquin County Ordinance No Joaquin County Public Health Services. Job Address 4907 Past Waterloo City Lot Size/Acreage 09) Owner's Name Ms. Carmelita Cozad Address 4907 East Waterloo Road Phone 931- 3098 2823 as M rtle St . Stockton 209 Contractor Spectrum Address SCt oco License No. 512268 none 465-8712 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT C DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ) OTHER Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LV i 1 Boring FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L 1 Industrial ❑ Open Bottom C-1 Manteca Dia. of Well Excavation_.9 ri Dia. of Well Casing / [.l Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications N A i'I Public 1-.1 Other n Delta Depth of Grout Sl�z____ — Type of Grout RP n I n n i t e/ I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by N/A J2,r- t Repair Work Done [.7 Type of Pump H.P. State Work Done, Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is l available within 200 feet,) ,1 Installation will serve: Residence_ Commercial Other Number of living units: ,Number of bedrooms Character of soil to a depth of 3 fees Water table depth \ SEPTIC TANK 0 Type%Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size- -FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number f^ 1 SUMPS LI 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, slate laws, and C) 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 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 tion laws of California." {r Persons subject to workman's comensa The applicant must cell for II req'uir inspections. Complete drawing on reverse side. e. Signed X_--__ O- Title: P r i n c i p a l Date: 11/5/90 Peter Alm i n e r ,S FO DEPARTMENT USE ONLY nate Application Accepted byDate �0Pit or Grout Inspection by DateFinal tnepectlon by I 11 Q TQ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, ffitvironmental Health Permit/Services I 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 / FEE AMOUNT DUE AMOUNT REMITTED CK All INFO RECEIVED BY PATE PERMIT CASH EH 13'24 IIIEV.r/"51 X7 EH;�.2e (/ (J ! U