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PPL1CA11ON FOR PERMIT - <br /> BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT <br /> ENVIRONMENTAL REALTB DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 RECEIVED <br /> (209) 468-3447 MAR 11 1991 <br /> PFRMIT P-XPIRES 1 YEAR FROM DATE ISSUED SAN JOAQUIN COUNTY <br /> (Complete in Triplicate) PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Applicestp U hereby rife to Ban Joaquin Coun,y for • posit to construct and/or Install the work eorun described. This <br /> applicatlp le cede In boapllance with Ben Joputn County Ordirei No. 549 and 1562 and the Rules and Reaulatipa of San <br /> Joapula Couatf Publle Maa1M Serylces. <br /> Joe Address 5400 Pacific Avenue Cily Stockton Lot StteMcraap <br /> O.'e Narne Montgomery Ward Addie. 3!-,201 Fremont Blvd. Fremont p <br /> 016 ?atu o La- t A 53H <br /> Cpdactar West Ilazinat Drilling Add,c$%Anahuim, CA 92805 LICenu No 554979 R,...714-939-685( <br /> _TYPE Of WELL/PUMP NEW WELL : WELL REPLACEMENT El DESTRUCTION ❑ Out of 8 1,11ce ell <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER Monitoring Well ET <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -- DISPOSAL FLD— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _, OTHEA WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Inaus u o 0 Open Sonom 0 Maniacs Do of Wait Eacavalron .� Du. W Well Casing <br /> U OMNIMK/Pavate ❑G10M soil 0 Tracy Type of Ca,mg— Specifications <br /> C3 Pubac ttl O:hW �] �• 0 Dv10 Depth of Grow S"� 7 pe of Gruul 10 to 1 ratio <br /> 0 Inp1,Ppn 3�lAopa..UepIR ❑Eastern Suntan SAW Initialled by ci Y cement t0 water <br /> Row Work Dons U Type of Pump H F. Suns Work DOM—with 3 tobentonite <br /> WW DeatUOW 0 WON DWneter Sealing Material i Depth <br /> Depth Piller Material E Depth r p <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIRIADDIT,ON❑ DESTRUCTION G INo MPaO Ween,grmnud d public"ryer is <br /> eesnablo..thin 200 lest.) <br /> IASIOUI"Mad"M: Residence_ Co,vnrt W_ Other <br /> Number of kynp urNls:_ N1,mbe,of bodlooms O <br /> Character of soil to it depth of 0 Mc Water tebte depth <br /> SEPTIC TANK ❑ Type/Mfg Capec.ly__ No. Compon"AIS <br /> PKG. TREATMENT PLT.0 Method of Dept"I <br /> Distance 10 nsaraci: Well Foundation P,epenV Lin 1 <br /> LEACHING UNE O No. E Length of lines _ Total tengmlarse 't'Y <br /> FILTER BED CI O.,tance to n"nst: WM Foundalron—_— Property Lina /I <br /> SEEPAGE PITS 11 Opts Sues__ Numb*, _- <br /> SUMPS LI Distance to natesi. Was Founauoa ._ Noporry I" <br /> DISPOSAL PONDS L) <br /> 1 he Aby candy tart I dere pop"W mit spit,81ron tnd fill the won w,u W done in accusing vilh San Jowuin cwniv ardirances.vote tewe, and <br /> rute41 and 11,9rNb0n,of IM San Joaqu.n County <br /> Home owns,or licensed agent,ergnalwo sendte,the fouowind i candy trot In the penmm,nce of tan work for which mu permit d Ostend.I MAP Mt <br /> arb010y any seared.m ouch rnanMf its to bocom.WONcf t0 wOnmp.l COmpeneshOn taw,of Coidionts"DOnlfeClaf'41 Tung Or WPtanitechng MBMWre <br /> comfort the 10"wmg:•1 eeNly IMI in IN pirta,MA<e of tan won for w ,ch mit permit te teW".I ansa employ person.Wa,eCl t0 wprkyo,n 0 cpmpen - <br /> Iron MM of CaklerMa." <br /> TN appkcerM v cap IW repueed n41pectrons CompNu W6.9 m 10.01"41,451, <br /> 5.0 IL Tate i �j4'^`t�. D.0 2`1L�Sl <br /> . F/OJI/f PARTMENT USE ONLY -J <br /> ,appucelron Accepted by !RrC%` Det. / - / A,.. ` I� <br /> ►A a1 Gro,.f Inepectron by Oa10 First Inspection by <br /> Addnronar Com,nn10 <br /> Aki.;IC41 -t - N.tirA 411 copies to: bAM JOAWU1M COUNTY PUBLIC HEALTH SERVICES <br /> LIVIN, .thrTAL HEALTH DIVISION PERMIT/SENVICES <br /> ♦Ad N bAn JOAULIN. P u bul 2000. bTUCKTUN. CA W3201 <br /> fit AMO�r.• LL. •Mi. a' el M.t rib T SAS•. "ICI.,, av OATt PERMIT MO <br /> ql-416 <br /> 2. <br /> 1+ <br /> ,QS't d� Copy <br />