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t 0Q-28-90 09: 29AM <br /> APPLICATION FOR PERMIT <br /> r <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIMTAL HEALTH DIVISION O SEP 2II 1990 01 E. HAZELTON AVE. , P90NE (209)468-3420 <br /> P 0 BOX 2009, STOCITON, CA 95201 <br /> pT'MIT 942"E4 1 TEAR ZRQX DATE ISSUED PERMIT/StERVICE <br /> (Complete in Triplicate) <br /> Application to busby made to Baa Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade in compliance with Sao Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health 3ervices. <br /> Job Address 2059 Navy Dr. City Stockton Lot Size/Acreage <br /> Owner's Name Russell Nelson ' s Address P .O. 29, Ripon 95366 Phone 209)599-42013) <br /> Contractor Kvilhau9 Drilll,n3Ad09, 1109 Landini Ln, Cps 482390 Pnone 415 685-6 1: <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER 0 Monitoring Nell jej <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INrt.rIULU ULL I VIM UP I'VELL PrlUel■/I ueeu 1,1.1111.1all, iii inn ser, Irn Ill., 1.110 <br /> it —.-. �. ..�. 1..1 <br /> 'v <br /> Cl 0..,.SJda:hrl�eu 0 Crewel red. ❑ Treey T>.po of Coeinp P11r, sosoalnvinne ri rTiirs 1 <br /> I'I Public Cl Other 11 Delta Depth of afoul Seal Figure 1 Type of Grout ("nncr t- <br /> I 1 Irrigation —.Approx. Depth 1 1 Eastern Surface Seal Installed by___ l)ri 1 1 i ng r n <br /> Repair Work Done U Type of Pump H.P. State Work Done _. <br /> WsU Destruction ❑ Well Diameter Sealing Material b Depth <br /> Depth Filler ldatarial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sower in <br /> ivallable within 200 Net.l <br /> Installation will serve: Residence — Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg _ Capacity No. Compartments <br /> PKG, TREATMENT PLT. Cl Method of Disposal <br /> Dlotance to ne6reit: Wall Koundstion Property Line <br /> LEACHING LINE C No. 8 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work wtil be done In arcoedancs with San Joaquin county ordinances, state laws, And <br /> rules and regulations of the San Joeauin County <br /> Nome owner or Ilcanead agent's signature certifies the following: "I carvfy that in the performance of the work for which this permit Is issued, I shell not <br /> employ any person in such manner as to become subtest to workmen's compensation laws of California." Contractor's hiring or subcontracting signature <br /> eartlflea the following: "I certify that in the performance of the work for whicn this permit is issued, 1 sholl employ persons subject to workman's compenss- <br /> rion laws of Callfornis." <br /> The applicant must Mg for a required insDe;tione, Complete drawing onnrroverse side. <br /> Signed x Title: _�/� �l�Q.bGA+Qt��. Date: <br /> FOfa EPAFIT USE ONLY <br /> Appllcatl ecepted by �'—� Date ZV — �� Area <br /> Pit or Grout Inspectlon by Date Final Inspection 5y Date <br /> Additional Comments <br /> Applicant — Return all copies tot San Joaquin County Public Health <br /> Services, 3mvironmental. Raalth Permit/Demises <br /> :601 E. Ratelton Ave., P 0 Box 2009. Stockton. CA 95201 <br /> FEE AMOUNT OUE AMOUNT REMITTED RECZIVED 3Y <br /> INFO CASH OATS PERMIT N0. <br /> . <br /> IM 13.74 AV.1r1411 &� ' 9n_777061 <br />