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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. . PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> P.EBMIT EXPI R4 1 y AR pROY DATE IRRt� <br /> (Complete in Triplicate) <br /> Application la hereby amide to San Joaquin county for a peralt to construct and/or install the work hereto described. This <br /> Joaquin County <br /> Sa Pude to lot*11Wwe with Ban Joaquin County Ordlnance No. 549 and 1962 and the Rules and Rs <br /> Joaquin County Publle Realth Strwic�a. �r AuLtIons of San <br /> _. Job Adore" f �V.w.. City/ �'- <br /> P"�•� �^ � Lot Size/Acreage <br /> Owners Nerve a Address Php,»9 - 11T-( <br /> r , (' <br /> Cpnhltty Addres2�_J <br /> Ment!No%���„� <br /> TYPE OF WEIU►UMh . NEWELL 0 Ell REPLACEMENT C7 DESTRUCTION O Out of eerwlce veil <br /> PUMP INSTALLATION O SYSTEMAIR 0 OTHER Q rmnitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICUL E LL OTHER WELL MTS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS <br /> (l limiu Mtel O OpM� "Om ❑Manes of VYee Eacevatlon Die.a Wed Casing <br /> !I OoneMlalHleew O GNwM Peck O T-" T a CeeelQ Speediesoore <br /> 1 I Punk n Outer n Oahe Mol Grout Seal <br /> t I brgeuen Type a Grsa <br /> —Alpea. Deph 1 1 EN Ow Seal Installed by - <br /> Mpir taNwlt Sane U Type a PtrnP H P. StS%Work Dona_ <br /> WYE DOWAsc*0 D Was ola"m 822112E Haterlal A Depth <br /> 0"Ih Miler Ihter a Depth <br /> TYPE OF S101K VAM. NEW INSTALLATION 1 1 WFAMIAOOITION 0ESTRUC 1 1 1� ft—Ooled d sauna » G <br /> wntMMiM1 VIA eery RMWIence__ Othllf , <br /> Nlrrlber a fNaily L.. Nwwbe►a 6 O <br /> Clereeear s een w•4100 of a Nest <br /> vwm <br /> SEPTIC TANK Q TT�e/M1E Ne.Corr�Oerimmon a -- ` <br /> PKG. TRSATMWT Plr.O Meu+oe of Dimmed <br /> 0111etaae h Ilaareel FourtdrR' Property Line ' <br /> LEAC11r10 Luft O Ne.Il Lett$IIL a Itrlee -raw <br /> FILTER 90 O DNattrtw w nevem tWSEC4 Progeny Line <br /> SEEPAfIE PITT I 1 Oeplt Shun <br /> MP <br /> SU $ LI OMrlw w 1NIaEZZ4A-w �2�Ptie0erfy lino <br /> DISPOSAL PONDS D <br /> 'hm*bV oereMY(NIM 1 Nelle ONM"d tads e119Yeesen and that the w0K r.d be due In eccordrtee wank Sen Joeptrin Cow"onbnote".SUN kws.end <br /> OWN tow NFAWm to of lite San.J"WA" ommo y <br /> Hanle esrster w feMMtt a el$IIe�N eMtlfiee Ile feaorrvtp:"I COWY thet M the perlornNrtte a the work ror whidl rliie pwnst 4 iselMd.I stlee net <br /> « MINIS in etMl1 tltellller A w aeoelte VA""b wtMkrrefl'e cowoo esuan wove a Caalomw**COONIOck /e I'W"of suseon"*"vq wWmtwe <br /> lien lerwe a ChEMtrtla~aeI1M�tltel in so PMltn <br /> emme of the Werk ror WAWCI+this 08mvt Is issued.1 Shell erroNy peeve stmom t w wnen <br /> ak 's cwnpenaa. <br /> The 81111111111011111 to r Irl►Cerwpele"wing an reverse side. <br /> r <br /> S~� TMw:— !! ✓7 a 0'.DEPA"MSNT USE ONLY 4�-a <br /> Aopft~ 0 "IV M Daw✓ A. �4 <br /> rw <br /> -PR Or Gn Atgp, <br /> an by �Lfzyll <br /> �- <br /> All'"di CaanentcSr <br /> AA1loaet - Ream all owLee tel "A its"U1e CatsSty Publie Realth <br /> r $emcee. Sewlrteziaetsl Reaitb Perait/eerwioee <br /> 1601 It, Eaeeltm Ave.. P 0 boar 2009. Stoektos. CA 9U M <br /> 111 AMOUNT Ow AMOUNT A1keTTEDCK a <br /> cAs REc[N10 ew oATt ►erlaei.4. N 1*ry s7z //�?w 0 1 1 <br /> r+0 <br /> saw <br /> t.- <br />