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FROM 02/ 10/93 1 4: 13 P . B <br /> V �l I�J4 <br /> T APPLI CATI O>N FOR PERK I T <br /> SAN JOAQUCOUNTY <br /> TAL UBLITHHEALDIVIS� THISERVICES <br /> iFEB 111993 <br /> 445 N BAN JO<AQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 WARONMENTALHEAM <br /> pERMIY/SERVICES <br /> PSS1fIT ��,�� . lam'$ I9�� � <br /> (complete in Triplicate) <br /> Appl.ieatios is imsto tsada,to am Joaquie Couety for a permit to construct and/or install the work herein described. This <br /> on1j etion is alsde in COW11anee with slat: Joaquin county ordinance Mo. 549 and 180 sod the Rule■ and Segulatione of Ban <br /> Jearlwia Owaty vW%ue Iitaltb larvioe.. <br /> Jab Address [So W• v�� 'i 1 i City �� t�C'�` SiSO//Acre.se/V()e S <br /> �.� <br /> Owfter's Nantes ,Il�S 660 K Address 3�3 S.�nP A mD A4694c, L k•P'hons <br /> C4rtlrsetdr L#q COta f-ry�llf-Sa, AdOmisS bS CuRpOenh'r [S� License No. Pnona�/� 1 <br /> TYPE OF WELLlPUMP: NEW WELL 17 WELL PIPLACEMENT ['h DESTRUCTION ❑ Out of Serviod We11 i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER>e Ifo iltwt'las Ifsl2 ❑ j <br /> DISTANCE TO NEAREST: SEPTIC TANK . .,,-^ SEWER LINES — DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE Of WELL PROSElM ARIA CONSTRUCTION SPECiPICATION --:3� <br /> D Ntdustrial rJ Open Oottowk Man" Dia. of Wed Fxcavation we, of woo Cashtg <br /> * Domemio/Priwta O Gravel Pick O Tracy Type of Casing.. SpaCificatiomta <br /> I'll PuOde Ll Olher Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigstlon —A9mon. Depth 1 1 Esawra $urioce Ileal installed by <br /> Repo Wwk Ostia 0 Typ of Pump 11 N.A. State Werk Oons y. <br /> Wall Owen ctlon •��°`( Wee Ola rata etalitta Naursal t Aepus T I - <br /> Geotn -� Piller Hat.erial A Depth 6. Tarv`'l'T x\ j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIA/ADOITION I I DESTRUCTION I I INc septic 6TTsesm pemrttittad it public aMww is <br /> available wnhin ZOO tMt.l <br /> inslsea*n win Il w Comrttereial— Ota* <br /> Number of NwV writs Number of bakoorns <br /> charasew at we w a depth of J IM: Water"bis depth <br /> idEPTIC TANK. a Typo/MIp Capochy No.Camawtn nu <br /> PKC.TREATM UR PLT.0 motholl at Disposal <br /> DYtertew to rte~* Well Powwolion Property Lutea <br /> LEACHING LINE Cl No. !tergal of lines Total fengthreii <br /> FILTEA ego O Olstanae to nares: Wed ., - Founewert Property Line <br /> UIPAGA►ITS 11 Depth sin Number <br /> SUMPt LI Dis ame to neersit: Was Founttatinn Property Lott <br /> DISPOSAL PONDS ❑ <br /> I N Mby oniflr that I have pispanad this applieatbn and that the work will os done in accordance wish Son.leatluln county otdinahces, state laws, and <br /> rulso Mad regulations of the Ban Joeouin Caitsaty i <br /> Hloms owner or livened apenfe somiurs osrtiRea the folkwAng: "l cortily that In the prformence of the work for which this pemrteit is issued. I shall not <br /> al"by any pnsOn in such fen ut0iaot to woroman's compensation laws of Califorais," Controetor's hiring or sub-Contracting signature <br /> DKWha Ute foagmwo g:1.1 hat in no rtprnsam&of the wank for which Ihis permir Is Issued,i shall employ persons subject to workmen's compenss- <br /> 1110ft Call auris.'• <br /> The sae squired I Comt"Is drawing on tovorw sift. <br /> $igrtad Title: til 1.1t [. Date: <br /> FOR DI:PARTMEMT USE ONLY <br /> AppNsatble Aco-otsd by Date Area a <br /> Ott or Growl lih pection by Date 2`/6� Final inevenion bySKL <br /> Additional Canwsnta: -3 . /-P 3 /0", <br /> Applicant - Return all copies to: San Joaquin County Public Health services 41.5d <br /> Snvironsiental Naalth Permit/Services ll <br /> 445 A Ben Joaquin, P O boa 9009. Stka, OA 9 <br /> AL40U I'DUE AMOUNT ItsMITTfO 'CII I CASH ftEt wwa eY DATENFO Pf1lHI17'M <br /> • HI tilt guy.mr•ir Q V V Z- f�• •® <br /> all ti•>t J <br />