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APPLICATION FOR PERMIT
<br /> ::XN JOAQUIN COUNTY PUBLIC HEALTH SFRVICES
<br /> mNVIHONYF.NTAL HEALTH DIV.SION
<br /> 16,01 F.. NAZKLTUN AVE. . PHONE (209)468-3420
<br /> P 0 BOX 2009, STOCKTON. CA 95201
<br /> }•t;ft�l},Z AItPIKIkS 1 YIiAR YROY DeTfi ISSUfiD
<br /> (Complete in Triplicate)
<br /> ap.:t.attea to Nr.sy Glad• --•,r.-y for a remit to construct And/or ]null the work herein dreeribed. This
<br /> o";Ilaltna is Ma. to 1-4% . •• + .'capula o.urty Ordinassee No. [49 and 106?AM the Mules and PeIN/attone of San
<br /> sraevta C•vt /ah/N/}Nlt". .. .'r•���j�} I •
<br /> City Lot Stte/Acreage
<br /> rY,..w.tiry __►.'_.�1.::�'fl . -_�.� ^�'-+_ ,S 1 / Phone
<br /> •s r ��...�� ,e A' •tt I�.r/_ Il ANY LrcMSeNof J ' 7trRonr C _
<br /> Til of MCI. • y/► r. htu WFII PE PLACEMf r' DESTRUCTION U Out of Service well 0
<br /> PUH►1%, 'rc_;A'r0N '-. SYSTEM REPAIR OTHER [: NOnitArtO� well �,
<br /> MST.%CE TO NEAREST Sf►TI( TA-.- SEWEP LINES ___ DISPOSAL FLD. PROP UNE
<br /> FOl'NDA1rON �—.__ AGRICULTURE WELL —_ OTHER WELL ►ITSISUMPS _
<br /> 04TE/aD1D USE TYPE OF r%Etl— PNOBJIM APE CONSTRUrT1ON SPFCIFICjhlVNS
<br /> /gAlAlrrer 0 Open Portnrn i Manteca r4a_of~Eacavason._ .__ DJ. of WON Casrnp
<br /> Der.w►t•►r•.ese (.1 afaoet Pa.. Tracy Type of Cawtq_ SpatdreatiOrta
<br /> ►rawt 1101%60 Dena Depth of Grout Seal Type of Grout_
<br /> w.psera■. ..- AOI•n. D.pth ' frits." Sunoco Seat lnstilaw by
<br /> Rape.Were rbery ,. Type Of P,,...tt -_ _ ___ N P State Wass Done— t"
<br /> Acer oewr lrao• Wes D•wt« osalltt{ Material L Depth V,
<br /> Darin Filler Material A Depth
<br /> .t'f UI "P►K WI)Ra Nf W W' •Ar I A fitly RE►AIWADDITION i , DESTRUCTION 1 , 1040 s.Otar owstwr pe.mttsd d public sewer is
<br /> i ov&Awft vv`~200 tw,I
<br /> Itytalwao,,we save Pesidont• 're•r•rPC.M /Z Other
<br /> N..wM of i-ara ,n••a 4 ,..trsgroo,na ,
<br /> Charact.r of oad to•dw$N nl i Ir.• _ _ Water table depth
<br /> •EP►rC TAfisa ( ►vDs h'; _ -�_� C&0_1111�74= No Compartments V
<br /> Parr TREATIAENT ►tT Method of Disposal
<br /> D.a•. ...+est We" C I^ Four",*.4C Propwrty Lina
<br /> r t A r..r+Nl,l tNf t ... �----+-"— ----Total yngtnIll 401,flf(i !•..•e .,I Wee 0,C r t Fnundatern M'ropt+v Lina
<br /> •.11►► d P•'i " . .` Sr1ls —Number --t�---- -
<br /> .::lrar•. I - ,•.r W.n ��� fitwndalmn ... _.._ PrtwMv Lww . .
<br /> •.r•r At r:•�!•S I
<br /> r...�t .soil"tear,na.s I•— •• i"woes wo,t/e done in occol Aance w,lh San Joaquin county otd,nances. state 4w1. and
<br /> •..!.•a•d try1 •r.. ..
<br /> ..,try„«.a •.
<br /> or s../ay.,1. ..try Ineuw,ng I eert•fV Ihat in Iha porto,narrce of the work for w•hreh this permit is e{suad. I shall not
<br /> ary.•.,r•.ly.r... �•s.+.^nye••., +►•.r yrt it,wnrsman t compensabon laws of Clldotn,a Contractor's hiring or sub contractmp signature
<br /> .wt.ya rM r„anwr,.y 1 fa r r, n - - "an:•Gr IM N.d►Idr whKh this permq is paled.I sha:i smplov Doesons subMlcI to Volkman a componu
<br /> ,. • 'o-s of Ce/.••r•a
<br /> fly 0/4'•••am nvaar.a-fai, ale.r., • ♦ •. .✓nlJ.l.drawing cwt fftwaa arch
<br /> y•y+t a r 1 , •�_Lf Tr111 �.._ _ ..._... __._—. Dale'
<br /> DEPARTMENT USE ONLY
<br /> rJ(Jnyr./LR+..y _ _ Ares _ Z
<br /> ar . ..... • -w •• r )'.•. '� — -..._--"—._ Dae _______� __.
<br /> 1•a .,y , 'e� r. 1 .17 Finer Inspec I,w,bit _1. -tt�1 [�.4..Sc�SG Dau_111L.
<br /> AI In %.runty 8.671• Health
<br /> -., r]nvlrrnwrtA: Health Prralt/Services C
<br /> "at►ltun Ave— i' t1 h,,a 2OQ09, SWcktan. CA 952(11
<br /> ,.r \• elM'•1 l` �.-T—` AE C"VEO Av DATE PEaMII h0
<br /> I:A•ot 1..-
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