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` APPLICATION FOR PERMIT 'I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O 13O% 2009, STOCKTON, CA 95201 JUN 17 W l' (209) 468-3447 Y R J-7� V�RO;'_liV/sc� 1TAL HEALTH (Complete in Triplicate) KiRMITISERVICE5 Application is hereby made to Sas Joaquin County for a permit to construct and/or install the work herein described. This application is sande 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 _ Phons2D_912 - 3093 3233 Fitzgerald Street Contractor West HazMat Drilling Address Rancho Cordova License No.C57-554979 Phone - TYPE OF WELL/PUMP: NEW WELL C3 WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ 3 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 551 SEWER LINES N/A DISPOSAL FLD.40MW-3 PROP. LINE N/A MW-1 FOUNDATION 65' AGRICULTURE WELL N OTHER WELL 130 r PITS/SUMPS N/A W-2 i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rltq-3 i.l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 3 inc Dia. of Well Casing 2 inch L) Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing PVC t Specifications M Public t l77Onnther Sand ❑ Delta Oepih of Grout Seal 50 Type of GroutPOrtl and&Bentoni tE C] I(rivatlon 1yAplxoa. Depth ❑ Eastern Surface Seal Inslalled by ILA & West HazMat Repair Work Done U Type of Pump H.P. Stats Work Done Well Destruction ❑ Wall Diameter Sealing Material i Depth Cement & BPn5_ri e x Monitoring Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G tNo septic system permitted if public sewer is available within 200 loot.) Installation will serve: Residence_ Commercial____ > er Number of living units: Number of bedrooms Character of soil to a depth of 3 feet. SEPTIC TANK O Type/Mfg Cap jpQ�I PKG. TREATMENT PLT. ❑ SnIANRS HI'W aH 0I'I9ff&j1 $.M"RMcM Distance to nearest: Well �_ Foundation Property Line LEACHING LINE Ll No. 8 Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Propeny Line SEEPAGE PITS II Depth Sue Number SUMPS LI 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 shalt not employ any person in such manner as to become subject to workman's compensation taws of California." Contractors hiring or sub-contracting signatwe unifies 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- tlon laws of California.- The applicant must call for all required ins tions. Complete drawing on reverse side. Signed Y ��y i ' Title: Geologist Date: 6/14/91 Herb Stefte Harding Lawson Associates FOR DEPARTMENT USE ONLY Application Accepted by _ / ` DataALI Area ��Pit or Grout Inspectionby40VDate Final Inspection by Data 3 r Additional Comments: Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CKCASN RECEIVED BY DATE PERM41 NO. INFO 1 / / 9 c��/ . EH,s-24uEV.,/Aei � 4r� .� •� `-�y A fr/1 JQ W / II 5 EH:l•2a CJ