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;U-26-90 09. 29AM
<br /> APPLICATION FOR PERMIT
<br /> i -
<br /> ,. SAN JOAQUIN COUNTY PUBLXC HEALTH SERVICES
<br /> ENVIRONIMTAL REALTH DIVISION SEP 2� ��90
<br /> i1601 E. HAZELTON AVE. , 1PEONE (209)468-3420
<br /> F O BOX 2009, STOCKTON, CA 95201
<br /> I' LIONMENTAL HE;..,:;
<br /> ••F,,�„pIREB 1
<br /> TW FROM RATE Zs,S= PERMIT/SERVICES
<br /> (Complete is Triplicate)
<br /> Application Is hereby made to Sea Joaquin County for a permit to Construct and/or tnatal.l the work herein described. This
<br /> application Is made in ooliliRnce with Sat[ Joaquin County Ordinance No. 549 and 1652 and the Rules Lad Rejulstians of $an
<br /> Joaquin County Public Health Sgrviote.
<br /> Job Address 2059 Navy Dr, '� S tockton
<br /> CitY _ _ _ Lot 81st/Acreage
<br /> Ownar's Name Russell Nelson ' s Addraea P .O. 29, Ri -on 95366 Phone 20 91 599-4201)
<br /> Contractor Xvilhaug Drill in AdPRa 1109 Landini rnL. Cor4IogA 482390 phone 415 685^6 I:
<br /> TYPE OF WELL/PUMP: NZW WELL ❑ WELL AlEPLACEMENT C" DESTRUCTION 0 Out of service Well G1
<br /> PUMP INSTALLATION G BYSTEM REPAIR ❑ OTHER 0 tdonitarinE Wall it 1
<br /> DISTANCE 70 NEAREST., SEPTIC TANK SEWER LINES DISPOSAL FLO,_ PROP, LINE
<br /> FOUNDATION __r.,._ AGAICULTURE WELL OTHER WELL— PITS/SUMPS
<br /> Ir[rLF1NlU ULL r V ue up,lw.1aLI- /1RueL.a?.i u
<br /> ! eau 1,1,uuelnn 1111111 wool 1001 1111111110
<br /> W Ir,V4wuselA..,., u i..rn...,.. ..�. .. ..,...
<br /> 9 D,.•:.ShclaJnrlaata Ia couMl dr
<br /> 0i. ❑ Traeyl T%1po al Coainp— PVfspooillowinns. r Cri,rp 1
<br /> I'I public M Other 11 Datta Depth of flrout SealFur _ _
<br /> � �` Type of Grcut__Cc�r�cr�,�,tt
<br /> I I Irfiyation —,Approx. depth I I Eastern Surfaca Saul Installed by G ,
<br /> Repair Work Clone 0 Type of Pump H.P. State Work Done CIA
<br /> I Wail Deatruction ❑ Well Diameter , Seali[+g Material i Depth
<br /> Depth I Filler Materiel i Depth
<br /> ii TYPE OF SEPTIC WORK: NEW INSTALLATION I I FIEPAiR/ApOITiQN i 1 t]ESTRtJ TION I ! tNo septic g;—stern permitted it
<br /> ptrbliC 4awar is
<br /> 11`1218111V01111 will serve: Residence . Commercial_.,., Other,� available within 240 feat.i !
<br /> Number of living units: Number of bedroom*
<br /> Character of soil to a depth of 3 foati Water table depth C
<br /> SEPTIC TANK, Q Type/Mid CapacitY_..,,...�`..� No. Campettments
<br /> P1ifl, TREATMENT PLT. L-1 Method of Disposal
<br /> OlgtanCp to nearest: Wall �_ ,,,,� Foundation Property Lina
<br /> !i .I
<br /> LEACHING LINE C1 No, Length of tinea Total Isnglh/size
<br /> �! FILTER BED .
<br /> ❑ Distance to nearest: We11 Foundation — Prorty Line
<br /> I! 1 pe
<br /> i' SEEPAGE PITS 11 Oepth I Size Number
<br /> SLIMP$ Ll Qistance to nearest: Well Prpperry Ling _..�.
<br /> 1 DISPOSAL PONDS 0
<br /> ,i i hereby eartiry that I have prepared this application end that the wark wik pa oOne In accapdanta whit San Joagain county ordinances,
<br /> stets laws, and
<br /> rules and regulations of the Sen Joaauin County
<br /> N4rhe owner or 1iCenead epant's signature tortillas the following; "I COMM that in the performance of the work for which this permit is issued, I shell not
<br /> i ampiay any person in such manner as to become subject to woritmen'a oornpgneeifon laws of California," Con[ract4r's hiring or sub•contravting signature
<br /> ionla the f aUai al '�t certify that in the performance of the work for whicls this Perm,t ii issued, i shell employ persons subject to woritman's compansi•
<br /> tion lawn of CAlifDrnia.'
<br /> The appimant must for 66 required inspections, Complete drawing on reverse sine,
<br /> 519ned x Title' _ / .
<br /> Data:
<br /> Ft?p PAR'S U88 ONLY
<br /> AQpliCatl acapud by -7pats
<br /> ! Plt 4r t31otat Inspection by i pate Final Inspection �� Dite�d y"G
<br /> Addiaanel C4mmertte.
<br /> Applicant - Return tall copies tot San Joaquin County Publ1a Health
<br /> 9amices, :avirortmenrasl Health Permit/5crvices t
<br /> t 7.601 Iii. Ratelton Ave.. P 0 Box 2009. Stoelatoo. CA 95201
<br /> INFO AMOUNT OtiE AMOUNT AEMtTTEp CASH RECEIVED 3Y OATa PERMIT-No,
<br /> !i
<br /> . Ik
<br /> 13,:4 IRtr1r.1i,tgl $f dC7 �j ' 771I ' /a��j�v �f���XY47
<br /> n I RM -4.4
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