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APPLICATION FOR Pia <br /> SAN JOAQUIN COUNTY PUBLIC �VIC15S <br /> 0 <br /> -MVIRONMENTAL HEALTH 13 Via <br /> 445 N SAN JOAQUIN, PHONE ( 3420 <br /> P O BOX 2009, STOCKTON, 0 AL <br /> FF (Complete in Triplic Y # W�� <br /> L• <br /> Applicsttoe !e Radebi I coo to ilea Jcequla [aunty for County <br /> Ort to ce two. t:L and the Yule. and liagulAtione of Sen <br /> app2leettoa 1r made In ct�llane+ with fled Joaquin COuniy Ordlnancr two. 54 ■rd 1$62 <br /> Josqulu Colntf Public mosath Bervicee. s' <br /> I <br /> Job Arfd.0 , Lot Site/Acreage-- <br /> f <br />! fr' Addretf q �A" PhaM <br /> .Owns'%Name J <br /> F <br /> ' ddrtss SRL t�St.Fidt�++ L•ctnse No. QLSQ - �r� <br /> I L11 <br /> Ctlnlla[1af <br /> TYPE OF WELL/PUMP; NE wELE ❑ WELL REPLACEMENT ii DESTRUCTION Out of storng 11.13 <br /> PUkAPINSTALOTION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> ttonwrin�Wil L' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION" AGRICULTURE WELL OTHER WELL PITSISUMPS .r <br /> q INTENDED USE TRIPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br /> 0 Industnai ❑Open Bonom ❑Manteca Ma.of Well ENcaveuen Dia.o}WNI Csaing <br /> j f.1 DorrsatielPrivata Cl Gfavtlt Pack L1 Ttacy Type of Ca" Spec"atioins <br /> I'1 Public n Other CI Deha Depth of Grout Seal TV"of GfO'rl . <br /> ,I I Inipation ..._Appros.Depth I I Eaatrn Surface Seel InstaMd by , <br /> FRepaM Work Done U Type of Pump _ � rN.P. Sure W Dona <br /> Woo DaStructiort VYre piSrtletw �` Beellnt Irurla2 a Ley[n <br /> Opth <br /> "T111er 7t:Lirlal a Depth ' <br /> j TYPE OF SEPTIC WORK; NEW It.STALLATION I I ItEPAIRiADD1TlON I l DESTRUCTION i I iHo sapl,c sy%Iera permuted+t prrbkc se+v+r r <br /> i available within 2W feel.( <br /> Instafletion will Serve: Residence— C"rciw Other <br /> Number of fiving tanks: _. - 'N 7-of tusdrbanls <br /> puractat o}sot!to a 0Saeh of "'! ! Warr table depth <br /> 1 i SEPTIC TANK t :fC1. �ypefAR}q Capacity No.Compuu+wts c <br /> PKG,TREATMENT Method of Disposal <br /> 1 <br /> Diaw+ce to tI%ara�_ <br /> at: Wee Foundation Property Lina <br /> LEACHING LINE L1 No.E Length of knee _ Totes tengill/site <br /> FILTER BEA 0 Diene we 10 newest. ra <br /> ' Won — Fowldeuorl Property Li <br /> i <br /> E <br /> SEEPAGE PITS 11 Depth Site Nand er <br /> SUMPS Ll Distance 10 rrest: ; Watt Foundatwn Properly line <br /> mr <br /> I : <br /> DISPOSAL PONDS ❑ <br /> ' 1 hereby cooly that I he"prop i rsd thi%application and that the work wAt w done,n accaraence,nth San Joaquin county admances.elata taws.and :3 <br /> f rules wd rpuAslgrrs of the San JOKIL n County <br /> t 'Borrie timter or kof SWI,o Sigheiure certifies the following:"I certify that in the perlprmance Ot me work}or which t%M permit is ieauea.1 tulteM r p <br /> tlnpby arty pwson Rwvlw es 70 become subject to workman's compontattwt ieuva of CMrlOrnia."Contrattao 1lisubjrvV c wPt:onueeting IRWOr,",. r <br /> ^, pftifiee IRs f I Artily that in"performrlca of If%@ wrrk tot which tlln pr(M is miusd.I%Rall employ PrreOn%wbpet 30,tw.krlwl'a cpnperuss rr. _ <br /> tion Iewe Of <br /> j <br /> T1»apPliclxft for as required %. Co m drewing txl <br /> SipMQ Title: Dau: <br /> y) FOq.DEPARTMENT ONLY <br /> 1Cf��-G7� v Argo r7a-Ips <br /> Applk;Stlon Aeapted by <br /> Data -- <br /> f � <br /> . Pit Ix Grout Inspection - Dau F,rtet Irlapaction by O"r� rA Datr .20;5 ; <br /> Addklonel Co nr U: - <br /> Applicant - Return all copies t07 SPO JOaqulp County Public lfealth &ervicea <br /> t invironsentsl Health Perst tl 9+rrl cee _ <br /> j 405 M Sas Joaquin O Box 9009, atka, CA 95201 <br /> + i r FE! Aktpt T DUE AMD:lM7 ntrr11T7.ED RECINiO Rr PATE rEAe.t1T NO. <br /> r"l} INFO CASK q <br /> ev j <br /> of j .Etat t},e ISfV.,rru <br /> iI <br /> 1 <br /> 1 <br />