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�... <br /> fS 415 54A.: 7496 RQlIi1 RESOURCES 05.02/90 t5122 P. 03 <br /> APPLICAT10N FOR PERM IT <br /> 8A9 i 6AQViN COUNTY NNZiC nEAUT'111 SERVICES <br /> IENViRONMENTAL kkEhLTH DIVISION <br /> i6di lig !lAft-LTON AVE. , 11116NE (208)968-3420 <br /> " p 0 AdX 90090 STOCK1'ON i CA 98201 <br /> A. <br /> 040 J?EUiT 1 RPIRE3_�YEAli-.FHO�_ <br /> �Aw <br /> (COMplOtee it Tkiplicate) <br /> Applleatlon is hereby h6dlt6 Ratti J664iulti County for i persalt to coh0ttuet ind/or inetali the work herein Aeacribed. This <br /> sot11e+tiee it "die iii 4641:1464ib Vitli Sio J"bilin County ord,tnanei Me, SLg in& 1862 knd the Nines and Regulations of San <br /> Joaquin County Public IINalth 80-viten <br /> Jab Addraie° fl8 n kl Lrit1 .=.l1TIi1 Skadiuiii Dr yr Stockton . Lot 91.1e/Acre#Lge 59.2 ac. <br /> Owner's Nert,i 5giiti Fe I7eve opi}ien>:. Addteas 0 40; .Box 2540; Fait' Oaks 95528 phone 916-783-0521 <br /> Conllaclol var.Uifo : Addresil 287.-5 .E: Myrtle i Stocktoticense"No, 512268 ;phone 209-948-1345 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well Cl <br /> PUMP INSTALLATI SYST% ErAfn Cl [} lAonitoring Well [ C <br /> redo' 'o'� >fdl >251 s <br /> DISTANCE TO NEAf1EST: SEPTIC TANK *• SEW0 LINES 7 DISPOSAL FLD. PROP, LINE: <br /> PouNbATION =2T AGRICULTURE WELL 710U2tOTFiER WELL> PITS/SUMP, <br /> 1NTENOEb,USE TYPt OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f'€ Indussrial C} OpNn Battont 0 Menteci Dia: aI Wall Excavation 1 ON. of Weil•Casing 2}T <br /> 1.1 Donastie/PrivatN X1 C,wv (lick L7 TricY TYbe of Caslnp PVC Specifications <br /> I'I Publlc 1:1 Olhir h [yips bbpih bf Grout seat 651 TYPe of 0fout see be1� <br /> 114rlpetion ,__ Aptiiii. 06ptt i 1 Eiiil$Fn Surface Setif Initalled by Spectrum lo `r <br /> Repair Walk N4 Li typi of Pump j1[tnd � H.P. ---RL09_ late Wprk Done <br /> Well Destruction D Weil blimater ' r.�.... , biftling llAtbtial i Depth `seer, ceme� wt L—J7. <br /> X Mcnitolrittg . Depth —�� PXt�� �r3f��� �_ Bentonite; to top <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUC71ON l l INo septic system permitled if public dower is <br /> avallable within 200 Jai t.I <br /> Installation will Cervi: 06iidene6— CorT nM#JclJl Other <br /> Number of I€v€ng uniik. Number 61 bje tbomi G <br /> Ch$rscter o1 toll 16 It depth of J fbbt Wttei table depth... <br /> SEPTIC TANK ❑ Type/Mfg CepAcity No. Compartments <br /> PKG. TREATMENT PLT,_ l_1 Method ob•bisposal <br /> Olslhitbi In hears#t: Well Foundelioh Property Line <br /> LEACHING LINE L'1 No. 4 Lcnpth iii iini# _ _ __. TOW forrplhiklie <br /> FILTER BED 0 d4lincil In h6it6it: Will I oundiiiais Property Line <br /> SEEPAGE PITS I f Depth Siie _ Number <br /> SUMPS (I blstincfi id tiiiMili Well Foundation-_-.. Ptoperty Llne <br /> DISPOSAL PONDS— D <br /> I hereby certify th$t 1 hivi pripitid ihii 66p0iitliiti roil.that thtl work will be dont in atccordene$ orith Sen Jo6quln county ardinencas, stili lours, and <br /> rules end reguiatiohi of thi! SAA,1oicittlri t;ounty <br /> Home owner of Iieahied aipiht'i ilpngfuto eeitifi$#ih8 Iopowing! "I certify ihAt in thi perfaimince of thi work tot which thle permit Is issued, I shall not <br /> emplay any petabn In$uih€hei4f At la 6666rr fi iobjfict in woikman'R cdmpenM16ri lawi of Cellfetnla." Contractor's hiring or sub-contraciling signature <br /> Certifies the toltowinp:"I tNriily thdi lit IM bii16tM'1iA4 l sf the work for Which this permit Is liriutd,I atlall•emploY pririont subject to workman's eomponsa- <br /> tion levy$a�t1 C1111forhICIP <br /> The applklaht in "1 tNlt.fpi l-;$ d inimellani. c6tiiplei9 drAwHe oin_tmtsa 1idd, <br /> Signed X Ti(Ee: ► rOr' .Cfir�r�a+t ball: - lr�+ C'� <br /> PAR i1SE ONLY Irl�h�it <br /> Application Accepted by _ Date <br /> Pit or Grout Inspeclfan b" l]aitb Nil inspection b Datr_�— <br /> Additlonsl Commarilk <br /> Applicant - A4j4ti iLil eoniii tot San,Jobgiliri County Public lleslth <br /> gervices, L`nvli•onm4nt4kl Reilth Permit/8ervicera <br /> 1601 $. ItAteltob Av&:c p D Box 2009r Stockton, CA 95201 <br /> FEECK <br /> INf0 AMDUHT DUE A.Mouht AEMItTED CASH RECEIVED BY DATE PERMIT'NM <br /> 13 IREV,riR%r 3,5 /g`9 4(� J.r" L'�O 7O' -��J�� <br />