|
i �, x :_ j it .
<br /> mal. �� ApPL•IC_1TT f}I+1
<br /> -
<br /> ''i'G=Y, 4'
<br /> "yam SAN ,JOAQUINCOUNTY PUBLIC HE TB ICES
<br /> W, �'..ENVIRONMENTAL .HEALTH DI ISI
<br /> t t:y i
<br /> 6a 45 N_,SAN'JOAQUIN, PHONE (20 420
<br /> � P O k BOX, 2009, STQCKTON, ; C
<br /> w k 1,� �-�sw, ,.a ya&. v•,ri r..�,p ' i era
<br /> R S' - YEAR FRO D
<br /> i , Complt:te in Tri Ilea
<br /> p rti f
<br /> g,_'S iib 7s t. a+ve-i;.� R�' "�.•,.�""r'r�,'j'4�,•. s ,.-- � ) •. 1.- .ji' � �I
<br /> Appllt:a6l9u is hereby" A •Bao Joaqula Couttty,!for a permit to construct a
<br /> ppj111pettioa ts,mn4h fksq,.Toaaµln County Ordinance No. 549 and 1862 and %he Rules and,Regulations of Ban
<br /> tTo4quip Gowity ?071g iiealt l3rvlcoa.
<br /> .
<br /> Cil �tOC}CtOri Lot 81xe/Acreage lkrr'�f i` r
<br /> .Job Address y
<br /> i �y � w ,f
<br /> b r w r 948-1101
<br /> } N+ma f � gAddress Sidllli? ctS dkloVe Phone
<br />,Y wa F 2825 E. Myrtle_ a
<br /> �.,` fig'._ T MxK^ti{fr }• 'S: � J? 'k5 k "� i , ' 1,t �.J 1 — :I
<br /> !#r Address'eStockton License No. 512268 _Phone 'l
<br /> on - 'i.
<br /> ado
<br /> `TYPE OF WELtIPUMP NEW WELL O„x WELL REPLACEMENT I,J DESTRUCTION Cl out'.of Service Well ❑
<br /> .. i ., , T. SYSTEM REPAIR 0 OTHERID Monitoring tfell ❑ i I
<br /> } PUMP INSTALLATION ❑,#r ,
<br /> v "r DISTANCE TO NEAREST: SEPTIC.,TANK r,,?SEWEii LINES ���5 DISPOSAL FLDi - 'y rPROP LINE _
<br /> rftFOUNi9AT1(}N � At`aRICLJLTURE WELL OTHER WELL PITS LIMPS
<br /> ry
<br /> 1NTEN13ED USEI iti1 TYPE OF WELL” �t}PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> ❑ 0 n Bottom .r © Manteca Die. al Well Excavation 1 011 4?° j' Dia. of Wall Casing
<br /> Ci Indust a : - 0 r' m 9 r
<br /> r TYpe of Casing_ 40 Specifications
<br /> 1 .p4^+a;tic/Prlireip •. fGl Gravel Pack , LJ,Tracy
<br /> I'1 Public '' a I:1 Other'%. r' +'� �'j�l Delta t Depth of Grout Seal a=- 48r - :S_ Type of Grout b�71t !+
<br /> I I irriggtion �.w j7�Appiox Depth I i Eastern ,' Surface Seal Installed by s� j 5 =
<br /> Repair Work Bone't I "TYpe 91 Pump H.P.
<br /> State Work sone i
<br /> 1 "WeH Oiarneter y Sealing Material 9 Depth L :f t �.
<br /> s WeH pestructton, '"❑� ,3t
<br /> Filler Material i Depth
<br /> it
<br /> iIYPE 0€'SEPTIC WORK NEV�+ 1�1STAELATION I I:�REPAIR/ADDITION 11 DESTRUCTION l I INo Septic system permitted ii public sewer is
<br /> a 'f i, r t available within 200 test I
<br /> 1 S V A i 1 4 r5 f* l�'�
<br /> qt�- raj• f �+ � 1'�3 d
<br /> 3 Installation wtH serve HasiQenca#;=;~Commercial 0cher"
<br /> Number p1 Ilvinq,units .. a: Number of bedrooms
<br /> Cheragigr o1'ttoil'ta a dept# of,.3 feat ; }
<br /> :.
<br /> � �
<br /> PEPTIC TANK '"ti 3 `�'Di Type
<br /> /Mfg Capacity is a
<br /> f,
<br /> .PK(i TREATMENT PLT, ❑t � gid,-�� ���, .,� {#: i „ . al�I . ► � ' _ i
<br /> F �S 11/a�/ !i ;
<br /> Distance to rlaarest Well foundation i Pro
<br /> tc.'.,�,': '. i° r 1.+,'�' T'tir=
<br /> r 'l
<br /> * EACHI�IG, LINE r' l PV: Ng. 8 Length of linea Totafl&@ N ' 1
<br /> f
<br /> ' FILTER BED 1 Q Distanca to nearest ,;Wali Foundation ENU1R� yNi�,4+
<br /> .a7.F i�.. l: r 1 i♦ L .- # .rI VISRO
<br /> $90PAGE.PITS I1 DP th= X d=,� '_ ' SRR '
<br /> � P a Number
<br /> L'lLliatsneerast ,fWeil i Foundation Property Lina
<br /> 'f DISPOSAL PONDS ' ❑ '
<br /> r" hergby,ciirttly jft,1 lierv¢praporpd this application pnd that the work will be done in accordance with'San Joaquin county ordinances, stale laws, and l a'
<br /> Lit
<br /> rules a [P{IMIs1ip{ifl o1,t# i Son'. ir,Qot npt Zy ids
<br /> H ma awnar A[lkon*(iverlt f+sigriotur, oartifiea this following: "I certify that In the performance of the work for which this permit o issued, l shall not .i }
<br /> 'empaoy,any per in riyalt mtnner#s to ams subject to workman's compensation Taws of California."Contractors hiring or sub contracting signature (
<br /> r6anifies.tha fall4witl F aartif that In 1 a sFrrtorrnartoa of tnA i,;r4rlt far whjoh this trPrt"11 iii lsiva i I shall employ persons subject to workman's componsa• '
<br /> r lion Iowa of Ill r e�p g , '
<br /> The apPlaCatit rn •f oil stir { Ir ins coons,+Complete drawing on reverse side. * !.
<br /> Title: Gaol ist .'
<br /> Do... 1-19-94
<br /> s �qr Mia a
<br /> FOR DIEPARTMENT USE ONLY
<br /> Y
<br /> 4 1
<br /> yi, z y tl- -
<br /> Applic#Il4n Ac spied by sate / Area CCC rr i .
<br /> l . j=•
<br /> Pit er Grout Inspection by ra Date Final Inspection by Data
<br /> Additional Comments `
<br /> A LicanL - nall co iea to San`'Josquin County Public Health Services. e
<br /> z sip 4f p ' $nvlronmental Health Permit/Services
<br /> s '• '445 N San Joaquin, P O Box 2009, Stkn, CA B5201
<br /> i��r� i U«s --' fid` ,�#�]•a :.:f'rt i l Sr9 a_:''-. � -
<br /> r
<br /> yrs"` INFO AA►9UNT Qt16a AMOUNT REMITTEDCASH RECEIVED BY t.;.GATE PERMIt'MO, r
<br /> tiY4 13.2.InEV.i it a, r't •::rm•rs 4:
<br />
|