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u" <br /> ar <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YFI FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> APplleaele. le herby foods, to San Joaquin County for a Permit to cone truce and/or imtall the ,ork harem deecrlb.e. This <br /> application is Foods la compliance etch San Josquln County Ordinaries, No. 549 and 1862 and the Rule. and r San <br /> Joaquin Count t�yC/Pvublliic Reaasl/4h '�Jrvicae..Z _� <br /> Job Address Qr19tJ� /Y. IM�t-lt/t4/'� �O. City I.ot Slce/Acreegu V��_`"I o7 <br /> Or'a NMre(J.,aSrl'J�?"�^ 4.�_ Address !_.� 1 e✓'Fi'V Phan. <br /> Weoo __. <br /> .,/[��//t�'//....//,, //�/5577��..// r �J�Q^J _ ..ems <br /> Coniracl Adaressj v�/!e-/��� License He.,LZ�Phnne 'y�W <br /> TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT E1 DESTRUCTION Ll Out or service Nell 0 <br /> PUMP INSTALLATION C SYSTEM REPAIR 0 OTHER 0 Monitoring well E' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER ONES DISPOSAL FLD,_ PROP.LINE ___ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USF_ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Imiusea l O Olson Sae m ❑Manteca Dia, of Wall Eauvatlon _— D4.of Welt Ca..ng <br /> El Domestic/Presto Ll Gravel Pack O Traq Type of CaemJ Sgohcauon._ <br /> 1'I Public ❑Other fl Delta Depth of Grout Seal __ Type of GrouI <br /> l 1 Inrpatcn _Approa.Depth I I Eastern Surface Seal In.alled by <br /> Repair Work Dune 0 Type of Pump H.P. State Won Done <br /> Wall Destruction 0 Well Diameter Sealing M.terl.l i Depth_ <br /> Depth Pillar wttrial A Depth <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION 1 I R AIR/ DD:nONK DESTRUCTION I I IN.untie ey.tei grmmad.I man., newer s <br /> IeMabla within 200 feat.1 <br /> Institution will fade: Resonance, CormrercW_ Other <br /> Number of Eying uriu: / Number o _ <br /> CNraCPK of"to a depth of 7 feat: Wafer Mole depth <br /> SEPTIC TANK b TypolikRil Capacity No. Companmunts <br /> PKG.TREATMENT PLT.O Method of Dleposal �y <br /> Distance to nwres:: Well Foundation_._ Property Line I <br /> LEACHING LINE No.B Length of linea � Tojal lenOthhize <br /> � <br /> FILTER SED Cl Malone.no anWild: Wyyc-a� <br /> _ Foundation — Property Liq S <br /> SEEPAGE PITS >< Depth Size Ijumbef _ <br /> SUMPS LI national to newel Well� FOuMeuon Pro",.,Lina,y__ <br /> DISPOSAL PONDS 0 <br /> 1 NrsbY unify that I Nye pragnd this application and tIWt the work will be done in accordance with San Juacl count,aidmance.. .late laws,and <br /> rules and rapulatiorq of the San Joaquin County <br /> aorta OWnar cr licensed Veni a.ignownr eMtilYe the fobwing:"1 Canify that in the performance of 1N work lae Which this remn is leo-.ed, I shall not <br /> employ any Fenian in Soon manroor,es to Notions subject to workman's compensation laws of Celifomia."Contractors hiring or sub-conn ncw•g signature <br /> cwdh"the toanwinp "I unity thot in the grfonnanee of the work for which this grtnt is issued.I i m11 employ peraam subject to wva o,_s comperva- <br /> don Lewis of caAtomle." <br /> The appdcant tt\W�ip Y dura al ,Done.Complete drawing a,,revaru/aq/eJJJ fns <br /> Bgntd Tide: US r [• Date- L.1�rlf�v .. <br /> U//tea � � FOR DEPARTMENT USE ONLY <br /> Anchorman Aeeaptd J6/L.L�D�2r,''7•/GG-a...i7 / Date ,s Ansa. .� <br /> -Orout Inspection Dy�J� "� at L Find Impaction by <br /> V <br /> Additional Con:mptt: <br /> Applicant - Re4Xa all COplea to. Sep Joaquin r:ouaty Public Health <br /> Samle", ILHrouedtal Health Permit/Services <br /> 1601 Y. Saselto,Ave., P 0 Bos 2009, nLaakte., CA 95201 <br /> IN E I AMOUNT DUE AMOUNT REMITTED ASR RECDYED BY OATS <br /> •ffl 11.1llYy..r.N ri9 .�� A <br />