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APPLICATION FOR PERMIT
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONMENTAL HI'1LTH DIVISION
<br /> 1601 E. IIAZKLT04 AVE. , PHONE (209)468-941'-
<br /> P O BOX 2009, STOCKTON, CA 95201
<br /> PERMIT EXPIIU1 YEAR PROM DATEISBUJO
<br /> (Complete in TrIplicato)
<br /> Application Is hereby made to San :oaquln County for a peralt to construct amt/or Install the work herein deeertbod. This
<br /> application Is made In Compliance with Ban Joaquin County Crdlnance No. 549 and l6b2 and the Rules mad eelulatlone of PaR
<br /> Joaquin County Public Health SOrvlets.
<br /> ob Address Lot Jleel A,'rO*PP
<br /> xownOrY Name TTfL+IJs.ai�t1T.�►Ai3+'�+ Addrea �51.14lI QL.. 1VJ MO^m
<br /> COnbdclOT•� ( _1 AA 1,ett ++ �(.� - L .rite hr vR.i�/��PMWS
<br /> TYPE OF '.YELL,'PUMP NEW WELL VvlLL RIPIACIN't"ol DESTnUCTIOfi , Out of service Well L
<br /> -- - i--�-- PUMP INSTALIA`IQN (: SYSTEM REPAIR WHIRRomiterinl Well r i
<br /> DISTANCE TO NEAREST SEPTIC TANK _ SEWER LINES _.-____ __ DISPOSAL OLD MOP LINE
<br /> FOUNDATION AGRICUL'UNI %%ILL_— OTHFR WELL_ O"711SUMPS
<br /> INTENDED USE TYPE OF WELL PROAIEM ARFA CONSTRUCT104 SPFCIFICAT ONS-
<br /> f I IndustfAl LI Open Sotto-. Manteca D,O of WOK Ea,"aann _ --_ _ -- DS Of~Cs"
<br /> 1!Domestc/Prwmle LI GlovM Pecs I1 Ttacy T too of Cas•-p -__._._ __ _- __— Sam+telaero
<br /> 1'1 P,Iblrc 1 1 Olhw 11 ONta M•pth of G•oul Ssar Teale of R'"' r
<br /> ll Irr,Oetwn .--- Aplwos Depth I I Eastern Lw,.._*S"Ineillow N ---
<br /> Rapaw Work Done i] Type of Purro _ H P _ _ --• _ State We.A Dome
<br /> Waa Oeftrutfoor, 2 WON Durmotet _ Fealirtl Material B C+tatA
<br /> Depth Filler "stomal 6 Depth -
<br /> ItPE OF SEPTIC WORK NEW INSTAttAT1D114' RIPAIR ADUITIut# I'MouITION rhocert.r systerwpertMteod'SO4bt bowaq
<br /> vNOOM
<br /> Intioatan w 111 NM RM,dence —__ Co-orvowcrN_ ptfwar .__ _-. I
<br /> Number of kv,np un,ts — Num4w of hed,00"..
<br /> Character of sok to a depth of 3 feel ._ --_ - -.-...._ _.--- _watts low Met►
<br /> SEPTIC TANK M T"*!Mfp _`~`__ Cklsc,h_ No C&v*W OMk
<br /> PKG TREATMENT PLT L1 Moll tod N 041posel
<br /> D,stance to rowed WON FoutMMlM _ ►totlenr lar \',
<br /> LEACHING LINE I No A Le,Vlh of what -._--_._.__.--__--_ TpIM IMQt% we_ _.
<br /> FILTER BED I I D-114-ce to-merest _WON _ Fo..,asalW -- Property torte
<br /> SEEPAGE PITS I I Depth
<br /> SUMPS I I Dstaoce to nearest Was touMeron PtopWtr lar
<br /> DISPOSAL PONDS (I
<br /> 1 hereby C*M.fV that I have p,apa,Od lh4 s,wket.on end mal the iA,.,k ft"be.%-e n a:;c•Aa•.a e.•th San l000-M e/wtr 404104W"L Mao lacca.dtd
<br /> rules and reQulahon*of the San J"Q.,n County
<br /> Monte owner or I,c Onsed agent a s.pnetute cerufax the fnmow,nQ I cat-r\that n the a of the*dA fpr*#weft IIIA Pa'rtns of,awted.1 alttd woe
<br /> etnpby any person to such nwener as to bot 0"sublOCt fu,A,Vto man s r0r 04onsal.nn lea$*t CeNr.►e Cnnitaclor a"at OW&CO Woov so,
<br /> eentfrs the folowwq "1 umly that,n IM psAarnr ee of tne v.ak for wh eh th•s I e,,..e,, ea ed I era employ Person aubfeet to work~a eowlPMrtee
<br /> tan laws rw..
<br /> TMs ant nttl am r onlplets drow+tp 0.Ie.«w s4e
<br /> Sped�- - - -- T,tle L-- Date _Aeni >t=�
<br /> �QIN DEPARTMENT USE OMIT
<br /> ApploCaton ACCOptOd NV -i r '-12ar��Ja-.H�`` .---- Data Li .1„ lyG� —�
<br /> 11, #41 �.
<br /> Pit or Grout Inepect on by Dale F"!Inspect.*-brryt&.� - •�`y`/
<br /> AddttanN CornmOnll --_�--
<br /> Applicant - Return all copies to: Slur :oep.to Cot..,ty PUbll- Health
<br /> Services, L,vlronnwntsl !.•alth rert,ltl3erv1cee
<br /> ltoCl [. flasel' a Ave..,,'F Ot , 'Y-19. Stockton, CA MI.
<br /> Fit AMOUNT Otil---r A./OW:T Rfk'"1D I N(CF,\109v DATE "Awl h0
<br /> INIO �__--__-1--CC SS-N— --
<br /> r ` /f p
<br /> aT E-• y
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