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3', <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I FJCVIRONVENTAL BEAJ,TH DIVISION <br /> 160I E. HAZKLTON AVE. , PHONE (209)468••3420 <br /> F 0 BOA 2009, STOCK ON, CA 9,N201 <br /> E4H 12ATE WI $Q , <br /> (Complete in Triplicate) <br /> i Application is hereby o t <br /> gado San Jos4utr C—nty far a permit to eenetrue_ and/or Saata_1 the worm herein described. This J:' <br /> s"Utslix so a4a in ecrpllenee with Bei.raaq-.ln Courty Ordinance $0. S4 ti and :$6? .Id the +tea and Hesttlationa Ot Ban f <br /> .Joaquin County FWb.11C Health Sex.lces. , ��� (• <br /> Jab Addr9sf _ -?--ia/P �D City %��_ G.t viae•/Acresee <br /> J3/� A / /3�/tE[{_ Address 7i u? ' <br /> Gwnar Noma L --- <br /> Co^haclar_� � f�VrOP - ACC:essJ�d,d�. .�- wrLi:ensr No. <br /> :YPE Of WELL.PUMP: NEW WELL CIWELL 11EPLALt..rIENT <-1 -DESTRUCTION 0 Out of iervtae Me..l <br /> ^ SYSTEMREPAIR C1 O'HER 0 ltonitortn8 Ve <br /> PUMP ff/STALLATION Cf : <br /> DISTANCE T')NEAREST; SEPTIC TANK SEWER LINES _� <br /> UiSPO�AL FLO. POOP.LINE <br /> LLL FOUNDATION AGRICULTURE WILL OTHER WALL i JT5.'SUMPS 7 <br /> INTENDED USS. TYPE OF WELL -PROBLEM AREA CON STRUCTION_SPECIFICATION$ - ' <br /> {;rndtitertM Cf Open BoHpm C7 Manteca Dia. of Well Excavation Dia.ofV,lep Ctakq <br /> I;Don:esticlPriwtla C1 Gravel Pack Q lrxcy Type of Casirq_ 5(vcifkalioM fPutific qtv4 Sr <br /> + 1:1 Other n Dots Depin of Grout Seal - Type of Grout T. <br /> r 1 IrnVe:K,r+ Appox.0*01 1 1 Eastern - Surface Swr1 Installed by ` -- <br /> tState Nn+,. Done_ <br /> Fepw Wort Cable U Type of Pump H.P. - ` S <br /> Wes T,)tatt-r.t�oe. fl Wee Di:xr+e'er <br /> Sea11tLS Materia' a depth .. <br /> D"th !Siler ys:tertzl m Depth <br /> TyNE O:SEPTIC V.CJt K: NEW INSTALLATION I I REPAIRIADDITIONA aESTAUGTION I I ave ablsop*within <br /> 2 feettred it <br /> INcpubl.sewer IsV <br /> / av7ilaLle within 4G0 feet.! .-1'► <br /> Insulation w o serve Raskienee—AC Corm"Feiill_ OIMr <br /> L Nwnbw of Wing uhits:--J-- Number of bedrooms 3 -- <br /> Ch,oWer of moi to a.siorh of 7 feat: bleier table dOPd+ _ <br /> SEPTIC TANK Ct TYPO/Mfg Capacity _. Na.ComPtrM-nts <br /> PKG.'TREATMENT'PLT.L-1Method of Disposal <br /> Oistines to nearest: V1ell Faundatinn Property Line <br /> 4f4f ffCt"��"•• 's• <br /> LEACHING LINE Ll No S Length of lines r Total lengihlous. <br /> FILTER BED Cl Distance to novitat: Weal--214fL Foundalmn f Property Lina. /d <br /> ' r rr Numbers`: <br /> SEEPAGE F41 11 Depth —LS Sits �— S <br /> 99 <br /> S,.'4 PS L.I D'atuxe to neargt: .vat! <br /> Foundenan Properly Lina <br /> DISPOSAL POfJO5 Q -- -------- <br /> 1 harecY tart,Ty;++st I have prepared this appliCMion and that the"Fk-41 be done in accordance with San Joaquin county ordinance,state taws,and - f <br /> rulOs and ro"IKKle of the Lan JOAQuin County <br /> HtYrM owrr+ar ar Ficcrts9d a�+nt'e aigna[urs Cen.tilf IM lo7ovnnp:'"I certify that in rhe performance tit the work for wi•.;Ct this permit Is'saued.1 shall ncf 9!Jc3- <br /> empty any panon'.�at tl7.Wanner as to became subject to wo kman's rampensal on Sawa of California,"Corntrsctoi s hiring or w►.•ontrxthp siQMtuea rt <br /> cvbfie■the 106n kv:"I cart3ty that in the performance at the work for which this permit is isauod.I shall employ persona Subpet to wbrkrtvft's COMPOr is. fi <br /> tion taws of Camotnia." - w <br /> The apps cant MKW CAN for ON reGuir-d n tions.Completa d+ewinq on re+versa tide. <br /> 5iprted w Gr/Y!F TRW_Cecke� Date: AL <br /> �J� <br /> i <br /> FOR DEPARTMENT USE ONLY G <br /> J J Date 7f _ Are: l : <br /> �i AppicatJon Acce941 by f <br /> PSt or Gmr Inspection by _ Data F,nOi Inspection by Due <br /> AdMkwisl Commenv- — - .,.. <br /> ` Applicant Ratum 911 eo91e■ to: ';an Joaquin Catnty Public H-%1th - - <br /> C.•reie¢s, Envirooeentsl Reslth 7ermlt/Serw3cea <br /> 1601 . Jlazeltoo Ave.. P 0 Box 2,49. Stockton, CA 95261 . <br /> fi <br /> FEE r'e I RECEIVED sy DATE PfPN.>>'mo. <br /> ICHipfl AMOr)NT DtJk AlAUU1IT RfMITTEO CASH <br /> tHt174rFSw. • Jf� f� �v Od �E ��• /!r/ ,_/// <br /> Il r <br /> i ' <br />