|
APPLICATION FOs. PERLIT
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRO.NYENTAL HEALTH DIVISION
<br /> 420 � 'S
<br /> 445 N SAN JOAQUIN,
<br /> p O BOX 2009, STOCXTON, CA 95201
<br /> PERMIT i'SfPinv� 1 Ys R FAOY DATE ISSUEt2 ND a l Liv/�
<br /> (Complete 1r, Triplicate) � AQ,
<br /> ua
<br /> V ,arrd 1867 and tM Rulel a.d R,N1At1on. of San
<br /> applleatSoe 1,"I&-stion to rd. ord�W rdtRiu lBufC oayulo CmuIty OrdimhcanNoN5t9 Mlor tn,ull tM1a rt here u
<br /> Joaquin County Nolle [ealth 51"IC41. t SIaI/Acr<a a
<br /> Joo Addrw "'IST w l �f—
<br /> C
<br /> O.vrwr'a Nam.
<br /> Licent< NoJ
<br /> j "the
<br /> ('RI IfL1 I �t.� r �r g I AdOrett
<br /> WELL RE PLACEMf NT fl DESTRUCTION [T(Rlt of
<br /> contact hrYf ee .13 O
<br /> NEW WELL O OTHER n Ra`a torlrtE veil
<br /> TYPE OF wELI/PUMP SYSTEM REPAIR ❑
<br /> PV MP INS 7ALUTION C DISPOSAL
<br /> 'LD
<br /> PROP. LINE
<br /> SEWER LINES
<br /> OISTANC[ NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL
<br /> NDATION S
<br /> INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SP Dom. 01 Was CROFV
<br /> It,Yation
<br /> C1 InduttrlN ❑Oph Bpttom ❑ M,nlec, S"tfk,norle
<br /> ❑ T, TYp of Cap _ p
<br /> f l OMM'"cip N.t. ❑ G,WM Pack ltaaytn nl crWl s.,l Trp d Grout T
<br /> I PIIORo n otiw, Q
<br /> p., paten 1 F,Nern 59Aad Se,l Inu,hd oY
<br /> bry.lion Slate Worl Don._ Q
<br /> Typ.of Pv H.P.�----
<br /> RepaY Wow s"lloE IeatertAL A DaptE
<br /> WN DwthwIN n ❑ Wel Di4en& r Tiller Ra•.ertal E Depth
<br /> Depth mttW X pwo: w.ee,rry
<br /> TYPE OF SEPTIC WORK: NEW INSTAllAT10N I REPAIR/ADDITION DESTRUCTION I „ wnlMn�200 jwt 1
<br /> IrNt&Mt aM I1MIM: Rlhd,,,,— CprrrvreW Other C
<br /> Nwnoar CO E.'"W urtim:__ NuntMr of o.doo,rla Wattle laole d,pM
<br /> ClwwNF of add la,depth of O foot: C,pcM No. Conlprt Alh a
<br /> SEPTI:TANK O Tma/M10 Method of DhoP0"
<br /> PKO.TREATMENT PLT.O FotRW,lbn Prepay'LXIa /3
<br /> D4t,nta to rraan: WN _
<br /> Total lergitHoUe—_ G
<br /> LEACHING LINE n No. , '.�' of arlea Propa,tr LII, U
<br /> FILTER RED
<br /> (:ID1nw
<br /> ,r,00I nr M: WIN FouM,lun
<br /> NVat»r (�
<br /> SUMPS RTS I I Depth SV,
<br /> Feurtduio,t ProPartY Lha `�
<br /> SUMPS .1 Obu,It+>D IIa„aer WM
<br /> DISPOSAL PONDS_'7 /
<br /> I hMepr eMif,NO,._ A prepa,ad I"IpYhtelloh aM that IM wOrl,nN bi dom in ICCprd,Ma min San JOgVin CWntr ad�,,o,4 stet,I,the, and
<br /> ,,0 and reQlllell.rN d IM Ben Jp,olr,I C ty Aoraa,Ka of IM wprY fa Y.hkh tM1�a perms k .Nd, I InIX n.I
<br /> Ndrle OMter IN kahead IOa,IR'a alp,NNt,cortitw the 1011 Mp:"1 canitY the h IM p
<br /> errtp/py,rlr pe„M wt: ow
<br /> Mich TYtrw w to LecMN WtNIc1 10 NcNtrnal-a CO,npenwlgn YM.'aauedXlanNl,mWoY p,rewla a�uDpptct 10 worYman�CompnY
<br /> Cerlllea TN,j0,,NNrlp "I cattily Mal h 11ta p,Aaa,rke of 1M wort la wM1kM1 roti peme
<br /> rity,I Iain d Cawarva'
<br /> ifr t p.a r a d ac e. C.aplell dnwlnp aO,grlrw,�
<br /> Title: �! Data.
<br /> Spode r
<br /> R DEPARTMENT USE ONLY
<br /> n w Data 11-1�-9Z An. t
<br /> AppReaNp,A wall by L D.I. L �Z"
<br /> Dal. F,hol lnsoo n oY
<br /> Ptt a Orad MuoettAon M
<br /> If A—
<br /> 'IQfr /
<br /> Adlrl
<br /> tb .l Co,Irtunu:
<br /> Appl{cant - ^
<br /> Itr lc
<br /> atvrn all copLa to: Eartro.Rwnt•IXeal to Perel[/dery{teare
<br /> 4ad R d.. JoaRuln,
<br /> P O Ron 2009, Stan, CA Pd2nI
<br /> ZET
<br /> Wl AMOl1HT RIMITT(0 t5 RECNYIO all OATE rlRMll M0.
<br /> "'" 39 Z S
<br /> —7 7oL l—1 l—5 `3 7-
<br /> . pqN qN L - -
<br />
|