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APPLICATION F01 PEMITI a(,(/For--"I 0— Zza <br /> "` <br /> SAN�A IN (AUNTY PUBLIC HSALTS 5L yYCS3 <br /> IR= SBALTH DI9I8I <br /> 1901 S. �PO� AVSN ox+342o <br /> pg �g� cs95ao <br /> (Complete in Triplicate) <br /> in <br /> 40"astioa is meretrlr comp o elan �iswe with � Joaquin Countor 46 ty Ordinance Enrmit to o.5169 and 1W and the Rules andeMN�ti Os of Sans <br /> ��� >!ttblia HsaLC� Ser+ices. <br /> ._ city Stockton Los sesta/Acreage 100ft <br /> 345 North San Joaquin x 3 0 <br /> job Address 2 North Second Street, #675 <br /> Pacific Bell ASan Jose CA 95713 P1oev, 408-491--4605 <br /> Outset s Nance ..� d�8Z.6 f mIrtiGCA <br /> Contractor Address License No. one <br /> TYPE 0F /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ OESTRUCTION ❑ out of eervsae We1I <br /> Hopitoring Well n( <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ 10 ft <br /> DISTANCE TO NEAREST: SEPTIC TANK -'500 f t SEWER LINES 5-10 f t DISPOSAL FLD�.�500f tpROP. LINE 3_ 500 ft <br /> FOUNDATION 20 ft AGRICULTURE WELL>0-0f OTHER WELL2,000 PITS/SUMPS LJt5 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr <br /> ❑ InduaW ❑ Open,Ooetom ❑ Manteca Die. of W411 Excavation Dia. of Wo C&*V <br /> 1=1 Donasticip"wate 41 Gavel Pack ❑ Tracy Type of Casing sch 40 PVC Speewwations <br /> 0-40 ft _ Type of � 3ft bentonit <br /> rl PubNc In Dow n Dela Depth of Grout Se41 2„ neat cement o <br /> I ;� Apprax. Depth 1 I Eastsm Saha Ss41 Installed by surface. <br /> Repair Work Dans iJ Type of Pump H.P. Sate Work Done <br /> VWM Dast[uetion ❑ Welt Dismew Saalu g Material A Depth <br /> TYPE Of SEPTIC WOAK: NEW INSTALLATION I I REPAIRIADDITION I I OESTRUCTION 1 I INo aeptic$y=permitted if p�AAC sewer a <br /> avewhis wrthin 200 feet.) <br /> Installation will serve: Rewdence— Cmnrneraiel_ Othar <br /> Nw dee of Iivinp weirs: Nwnbw of bedrooms <br /> Chwrnw of all w a depth of 3 feet: Wear table depth <br /> SEf TIC TAW. ❑ Typefwg Capacity No. Comperwrants / } <br /> PKO.TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: WaE Foundation Property Line <br /> LEACHING LINE 0 No. &Lwsgth of Eras Total length/ V <br /> FILTER BED ❑ Distance to newest Wait Foundation Property tine <br /> i <br /> SEEPAGE PITS i 1 Depth Sin Nwnbw <br /> SUMPS Ll Dia mme.to newest: WaII Foundation Property Line <br /> DIS mit PONOS ❑ <br />` i haebf aanify that I have prepared mist application and than the work will be dors in sccordeme with San Joaquin county ordUmmu a,sus*lewd, and <br /> runts and OVAetiona of the San A"uin Counter <br /> Horne arwtM or Eaansed agwWa alwwwo A wifiea the following: "1 car*that in the ped0ar-sn"of the work far which this permit ie iaasrsd.l shat)not <br /> MnPM1►atM fsaan H each nsensrsar a m beoonw etngret m workmen's pornpenMtion laswa of CaEfomie."Conorsctols hiring w sutreontr+at;tin0 sipnsatwe <br /> c- tifli Nth f0ftoring:"I aunty that in the perfonnenee of the work for whish thio pwmit is WwAd.101411 0114ft Pwaft subject to wakrIwo's aampeM- <br /> don Iswa of i. <br /> TheAIiIQNrie drawing on fevw"aide. <br /> S�t� ► Tak: Project Mena er per; 11/25/91 <br /> _; FOR DEPARTMENT USE ONLY i L ,! <br /> AppEauea <br /> lan Apad by Date l 3 Q Are, tJ+t•LT `C <br /> Plc or Orae! by Date. Fina)Inspection by. <br /> Data <br /> AddkbW ConenarM '9' <br /> /f9ltaaart ilettura tall 0091.8 t:or flan Josgsrin C0=%7 Pout health 24.Ca <br /> Services. ft"romantat aealth Psrait/serviaw <br /> 1601 B. aasalton Ave.. F 0 Hoc 2009. Stockton, CA 95201 <br /> AMOUNT Ow AIMMAIT RUWMD SH RECevo iY DATE Putm T'No. <br /> WFO <br /> .a tea trtev.v R . <br /> 16' w—pop"'I" <br /> S4. as93fid..M. 17M4E( Rin-3043 <br /> err asst <br />