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{ APPLICATION FOR PERMIT 4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ' 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 S <br /> L7 RPI S 1 <br /> YEAR-- <br /> FROM DATE I�IBIi <br /> (Complete in Triplicate) <br /> 'j Application is hereby made,u San Joaquin County for a permit to construct and/or install the vork herein described. This , <br /> app11cat1oo is mads Sit eoeplian.•e vith San Joaquin County Ordinance ho. 549 and 1862 aM_ the Pula• and Re6uLtlons of Ban f8ka <br /> Joaquin County Public Health Services. syf - - � <br /> City C� Lot 81 se/Acresec <br /> Job Addreu ? <br /> Address pJO Q <br /> JUL <br /> Phone a t <br /> 'rl ..Ownar'aNams <br /> T +ZOIC 7�n� Sly�_ 037 2Z�i Phone <br /> Address r License N _-- — <br /> � COnlra[li� DESTRUCTION p Out ot.Service Wall O r, <br /> d NEW WELL D YJELL REPLACEh1ENT.❑ monitoring Well D <br /> .TYPEOFWELLlVUMP: <br /> - <br /> - E <br /> t e` PUMP INSTALLATION D f PAIR <br /> SYSTEM RE C3. <br /> OTHER D <br /> ;_"A K t r yt g a DISPOSAL FLO. PROP:LINE r <br /> ' _ SEWER LINES <br /> a f..DIS7ANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> x ytY1� FOUNDATION AGRICULTURE WELL OTHER WELL v <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> }� -- Dia.of Well Excavation Oka.of WeN Casing <br /> trv -0 Industrial O Open Bottom ❑Manteca Specifications <br /> Type of Casing <br /> (1 Domtstrc/Pr!�ate O Gravel Psck: `- ❑Tracy Depth of Grout Seal Type of Grout <br /> z' I 1 Publk F1 Other [-I Delta <br /> 'a <br /> aNl I In aeon 's Approx.Depth I I Eastern Surlace Saul Installed by - - <br /> j My State Work Dont_ .�• '"' y <br /> PRparc_VYork Dont; L7 Type of Pump Sealing Material b Depth : <br /> a �y <br /> Well Destruction O Well Diameter <br /> rr '� liar Wteriai III <br /> Depth <br /> rrF: zst F <br /> Depth <br /> a rmAttd rl pudic sewer is' " <br /> Y avafht>fe within 290 feet.) <br /> n / TYPEOPTIC W(,RK: NF.'N INSTALlAT10N i I EPAIR DDITICN CESTRUCTION I 1 " aeptrc system 1» <br /> 1 �, •die <br /> rrt,(({{ tL t J1F^�yiKa <br /> .Y"{. M� (rtsteNOt{pn w,;l serve: P.esidena�. Commercial�n0 <br /> Number of ooma --� •^``• ••+�-^^ <br /> xa # N� �0 pvnq un ca: 4 �a N star It Wpttr <br /> s.� _ <br /> 1� rirYCtK of wk to s depth of 3 fast: Ca ity� ` <br /> o CompeRmen <br /> ... <br /> r 9 SEP�TiC TANK D Type/hifg Ma of <br /> PKf3 i�{Fj1TMENT PLT D <br /> +,.Weil <br /> Foundatan <br /> + th3 Distance to nearest. rtr <br /> M #t r X <br /> t tspo i <br /> ' Lina <br /> Pr i <br /> No.S Length of lines 'fid•' -. `� , <br /> n 4 <br /> Foundation <br /> Property Line <br /> . Ll <br /> Distance to nearest: 'Nell,5�_ '" <br /> FILTER 8E0 <br /> ls,h.J' Number <br /> t Sine <br /> SEEPAGE PITS e 1 .Depth +^ r <br /> Property Lint <br /> Well_ Foundation <br /> �SUMy ` j is LI Distance to nearest: <br /> DISPOSAL NDS' ^ ❑ s:- <br /> ,r cat on and that tits work w01 bt done in accordance With San Joaquin county OrWneflClf�atete lawti�ersdy <br /> 1..µ m> Certlly ttu3.1-have p eparod ilio aPW yna�t <br /> tkuts of the Say Joaquin CouaLythell not <br /> r -j�, taiNf nt'r Joaquin <br /> Certifgt she-following:"1 certify that in tf.o'pnrformancs,of the work for whkh thin permlLM n c <br /> y;r H �pipets►nor licensed aW <br /> °�y`pprtion M such manner as to become wbiedt to workman's compensation,4v+s o!California..,!Calrfomra.;Contractor's o subring or to%; ntreetn0 !t <br /> ?Ae fokowirW 1 cantly +et ei IM pe totmance of the wor for which th$'parmi[is,slued I rhalf employ Perrone subpet tO M�etk R <br /> ,1 ^ tloYt'Ilski�at CaLNornis + _ <br /> -� a ..eaU for r i ktspact ions. ComF�lete drewmp on reverse <br /> nt <br /> T 4�. ��k+.��•.a5� -'� <br /> FOR DEPARTMENT USE ONLY <br /> o ff) �hy �F Y C� Dais Ar"', <br /> Nd by ��� Osti—'! r <br /> f AppNcetlon I1eap � <br /> Y - 09to .pins'Inspection by_ <br /> Ion h <br /> 2, a PItCr <br /> n <br /> z` 9 Additwnlmi <br /> J�"`` Sea te,: Sea Joaquin C—ty Public Bealth <br /> �' ky7 ' AypliEttaLl�`Hetnra all cop fervices, Jsvircomenisl'Sea'_th'Permit/8"!-ices <br /> ; <br /> Stockton CA 95201. <br /> 1601 E. Iiaselton Ave..•P No <br /> O x 2009. <br /> RECEIVED 8Y rt;% GATE <br /> h. <br /> AMOUNT REMITTEC ".CASH <br /> .� r .FEE AMOUNT OtJE � <br /> • p � }aa INFO <br /> T <br /> �,, <br /> tit(UIN tlasl `\•,I �� `1• - :. .. <br /> ,` - � -., �EN S!•!e< r.�M"�.0 y. ;... .. ;n.tum+'�e,a;2- ."'., .ak,+da+tib.;t;�.'ri:�'.=+�-�w�sc+�.-w'rn.'°a"'`."`�-«. ��,ti x <br /> .� z s#"..� � ��;u-+.,m. ,s�svrtt•�3�:v�'�'"ee�yt""e'a�,��s+x�::m+was� � �. <br /> IN <br /> ro-111-i" <br /> f � <br /> skin +, 2' � qr;,or.+'fir � !� p r�•*y t �,yr,f:a "' � r.*c`�.:{'r °r 1.Y .. i � r.rr� ��t F+(+l•` <br />