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APPLIC.:TIOH FcR PERMIT ~~ <br /> SAN JOAQUIN COUNTY PUBLIC "ALTR SERVICES.—. r� <br /> -NVIROMMENTA.L ij.SALTH DIVISION . � If <br /> p 0 SOX 2009, STOCKTON, C3 95201 T <br /> a�., <br /> (209) 468-3447 <br /> PEUI APR 1591 <br /> tComptete 1:1 T:1pil:aLe� <br /> ..pplicai:ca :a neretrY Made to Saa JrxgU,p County for a permit to Ceratrnet and/or instJslllr titKt7iaa>�p 0.t crlbed. ':'`.Ls <br /> ayPlicatica is a542 in r�pllance vita San Joaquin Ccunty OrdLaaJ3ce ft0. `.L9 and 1862 and tttaf q���o+ at San <br /> ;aaquia County Fvbilc dealla Senlces. 4 <br /> y /�t.tU-2 _,I,, ~Y �"(tiLar 91 cel Acreage <br /> ' <br /> ab Aatlrna �"1c'Sr ' L <br /> ,t/'S w[vl �;(• � f—fir Phan 'J <br /> 7wner a Name i i l,, A. C-In� Aadteas 22 _ <br /> �s—s`", r Ya..ca, Com.-- ��5 —�71 Z <br /> contractor address <br /> ZJ F H 2 cense No. S ZZ� P^ane <br /> WELL REPLACEMENT G DESTRUCTION ❑ Out or Serlic9 Wei <br /> TY 'Wl L� <br /> PE OF NEW WELL M REPAIR Cl OTHER F AcaltorIng Well .K <br /> PUMP INSTALLATION C SYSTEM <br /> DISPOSAL FLO. PROP.UNE <br /> STANCE TO NEAREST: SEPTIC TANK SEWER LINES —��— <br /> DI <br /> GOUNOATION r � AGRICULMAE WELL — — OTHER WELL— PE7315UMP5 <br /> WTENOEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTSON SPECIFICATIONS <br /> a industrial C Oran 0onom a Manteca Dim.or Wag Excavation <br /> Dia,of Wae Caning <br /> ��� 4.0 ?JCr Soacrttutrona. f <br /> J OamaatterPnvate i Gravy Peek i7 Tsar Trf»of CaWnp__.— <br /> Public <br /> 1 Othat 0Delta Depth at Grout Seal /� {' !S _ Type of Grain . <br /> Irrlgatwn 02 Depth P Eastern Surtice Simi Instauao W <br /> Agoar Work Oon9 L3 Type at Puma H.P. Sues Work Dorsa <br /> JHtt+rLLL i Dept a <br /> Wall Destruction L] Wag DiaDiameterSasllnd <br /> D"tn PSller Material h Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION L7 REPAIRIAOOITION I7 OESTRUCTION CJ 4140"09C <br /> a�vnlMn 200 f+at!�ystem permitted <br /> tk bw sir <br /> stapslion writ Sam. Reei*ence— Commercial— 0010 C <br /> Number at tiring units:_ Number of 5+droame c <br /> t Water tab+again <br /> Chu+clar of soi to a*spin of 3 1941: menl <br /> it <br /> SEPTIC TANK [3 Ty"IMIlp CaoscnM+thd of Disposal <br /> I c <br /> PKO.TREATMENT PLT.G k <br /> Dirs+nu to n4arm: Win Foundation„ Prooeny Line <br /> I C <br /> LEACHING LINE -1 No.d Length.at lines will Iengthlsrie <br /> FILTER BED Distance to nearest: ,Y*A Founastion Prooenv Lin <br /> SEEPAGE PITS 11 Death Sil■ Number <br /> SUMPS L1 OiaurwA to nareat: Well Foundation Progeny Lino <br /> DISPOSAL PONDS <br /> I nsleov cenity that t naw arspare*this aporcatron dna tnal tate Work Wul be cans to accomance with San JOtagln C9UnlY ar*inn nCO,aUl+lawn,dna <br /> rules aria regut+lrons of the Son Joaquin County <br /> Home owner or licensed agent signature candles the lallow+ng:"I Lenity that to Ins penormance of the warm for ymltn 1hil birrrmt i9 saU'ba,I shell not <br /> ctOr'S til' <br /> ci Iles the ng signature <br /> employ any ogaw,ng:rson inaul hch ythhat to to penarmancef Is 10 became tott the worm afor wh cnthis tparnnt is tssu+al,fI sues 4mPicysPersonsrsuoi Octng i10¢warathtan!e cc <br /> moonas• <br /> Ion laws of California:' <br /> The apWtca as ag far ad raauuad in s Comolsu drav mg on reverse side. <br /> Signed <br /> Dat+: <br /> Title: <br /> (� <br /> FOR DEPARTMENT USE ONLY <br /> Area�---� -'--- --- <br /> Appbcahon Accaptsa by <br /> P11 Of Graut Inecactsan OV oats Oats �—Final lnaaacbcn by Data <br /> 'Jitlansk Comment{: <br /> wVpllcast - datura all r.;3,42 to: Sul JOAQUIN COUM PUBLIC REALTB SE&YICE3 <br /> ENVIRONMENTAL UEALTU DIVISION P£JIYITISERVIC <br /> 445 H SAN JOAQUIN. P 0 BOX 2009, ST0CXTCI, CA 95401 <br /> s s EiVEO!Y OATE PER1Att fl O. <br /> FEE AMOUNT OUE t AMOUNT REMITTED I t I <br /> :NfO <br />