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�3. <br /> APPLICATION FOR PERMIT <br /> BAN JOAQUIN COUNTY ptMLtC HEALTH SERVICES S3:)1AZ3Sj1IWb3d <br /> ENVIRONUENTAL HEALTH D1VISION 1YN 1YIN3Y1NO�111N`I <br /> —a E. HAZELTON AVE., PHONE (209)468-34�� <br /> D P O BOX 2009, STOCKTON, CA 95201 0661 go Nnr. <br /> R TqqllM <br /> (Camplete in Triplicate) Q8A13739 <br /> Applicatlas if hereby Std+ to 8.0 doitgriip Ctauaty for n permit to construct and/or inet+sll the vor <br /> j.'g1 A"914-d. T'tmia <br /> application it *Lds Lit ebo!blinctl with Ban Joaquin CQ=ty ordinaaee Ile.. 549 and 1B62 amid the Rulea and Regulations of Sen <br /> Joaquin County 1`0110 HeAlth Sarviess. 2-1 <br /> C�,,e,r City�1 _ Lot Size/Acreage 7� — <br /> Job Addreai t <br /> �°1pt,o��T.oS 3 S_ <br /> Owni a Natra drew . <br /> � I q b License Na..2.Ls��r'hene <br /> Conitaclor `lt� _,Address LILA 26 <br /> TYPE OF WELLIPUMP: N WELL ❑ WELL REPLACEMENT C3 DESTRUCTION l3 Out cf ?arviee well Cl <br /> PUMP INSTALLATION l3 M REPAIR 0 <br /> OTHER f] Monitoring Vcl1 <br /> DISTANCE tO NEAREST: 90'ht LANK —�- 5EWER LINED r ____DISPOSAL FLO.� FRCP.LINE Z <br /> . FOUNDATION .�S/ <br /> AGRICULTURE WELL OTHER WELLA PITSISUMPS <br /> if <br /> INTEN4E0 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC 1. N5 Ola,of Well Ceeinq <br /> fl lnduatriai 13 Open Haltom. 13 Manteca Dim.of Well Eteevatidn t Za �o f <br /> PVG Specitleations <br /> f I Dan+ettklPrbtieilrlvM Pltk ❑Tracy ,�1 Type of Cuing , 7r�of Grout <br /> I't Public �f 1:1 plher Fl Dnita L Oe i Depth of Grout Sell <br /> I I PuIffiblic 0 Approt,Depth I I Eutem Surface Seel Instatied by <br /> Repair Work Oona [] Typd of Pump uAr H.P. State Work 0 <br /> e a <br /> Selling MaterW i Depth <br /> Wep Destruction C3 We%Olamstat - Filler PAt-drial i Depth <br /> Z I.,, 8/►'. Depth-- :r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlAD71TION I I DESTRUCTION t I Ivo UP1mablewhhpermitted <br /> ln 2f%1 faetlII gables*war is <br /> insiaAatlan%d aa", AMldarted� datninlrClal_,., Other <br /> Numbae of Ivklg MAC Number of bedrooms Wafer table depth <br /> Chertmar at soe to t ri2mth of j feat: No.Compariments <br /> SEPTIC TANK 0 Typlimto Cspaclty <br /> PKC.TREATMENT PLT.') Method of Ohlpossl <br /> Dltttnce to earett: Wee Foundation Properly Line r <br /> LEACHING LINE 0 No.E Length of linea Total Iengthlaise^ <br /> FILTER BED Cl Dlalince to nearest: Wait Foundalkn Property Line_ <br /> SEEPAGE PITS 11 Depth Site Number <br /> SUMPS LI Distance to rldd:est: Wait Foundation Property Line <br /> DISPOSAL POND3 r 13 , <br /> 1 harsby Certify that I have prepordd thll spplksllon and that the work will be done In accordance with San Joagijh County Erdinmas,state laws.and <br /> ru4&and ragulstians of Ihd tam Josaulrt COU120 <br /> .. Here owner er Adklldd dgant•E/IDnaldia cartiflas the foloWng:"I cattily that in the perlaimince of the work for which this permit Is issued,I shall not <br /> employ any pdtetut In such mann*sl lb become euble4t to workman's compensstion laws of Californ[s."Contractortrhiing or to vrorkrmanfe ng bonen aa• <br /> urit <br /> esnHlH toe IotlomalklD:"I Cerdly tIl/t fn the petiornisrlcs of the work for which this permit It Issued,100 amploy pe <br /> ffans tion laird of Warm. <br /> Theapp.kin Must call fdt!1 tequkld klapoctioni.Complete drovA arse side, r <br /> i �7�. �,d k. Dote. <br /> Signed .� �!� <br /> '6AL Df1l a ART E ONLYl/ ,) <br /> Applkstlan Accepl/d by <br /> Oste Aces <br /> Ph or Grout Inspeelbn by <br /> Dale Final Inspectlan by Date <br /> Additlanef Codtmtnts: <br /> Applicant - 1t01 ra all copies fol Baa iosq'Ci�ouPublic tealth <br /> Plr�ti/BEnicte <br /> 1601 2. Hazelton Ave., P 0 Bax 2009: Btopictoa, CA 95201 <br /> FEE AMOUNT bUE ` AMOUNT REMITTED CASH RECENED BY 7ATi. PERMIT'kO. <br /> INFO <br /> . rN qi6[a[Y.lra al <br /> lH 16.7a <br /> ii <br />