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APPLICATION FOR PERMIT <br /> SAW.j0AQVIN COONT1 POLIC H-RALTH 1. ,RVICRS <br /> ENVIRONMENTAL 1IP3ALTH DIVISION <br /> P 0 13OX 2009, STMKTON f CA 95201 <br /> (209) 469=3447 <br /> (Compl.ote in Txiplictl.te) <br /> Application to f,eriby MA* to 04kh itoApuin County for A permit to cOnetruct and/or Install thework herein deearibed. This <br /> epPlicetion to bade in cooilience with BAn do*gnin County Ordinance No. 549 and 1962 ImA the Rules dnd Regule,tione of Ban <br /> Joequiit County Pubiia R#11th 66r•ie0e. <br /> uJob Addleis 69a �gjU 6U AAi ul` city L n Lot Otte/Acreage <br /> y. Owner's Nam$ tjgYLWn& f dT, f7t,11,kat Addrm! a ' ___-_ Phone <br /> ' �s7 <br /> Contrrclar Address qua f'IZ yUr'Q��I�cFnse No. Phone ? <br /> TYPE Of WELLIPUMP:, NEW WELL Q WELL RfPLAC'EMENT F] DESTRUCTION C1 Out of Berylee well Cl <br /> PUMP INSTALLAIIO d SYSTEM REPAIR C7 OTHER Modi�toorring Well <br /> DISTANCE tG.NEAl1ESti, SEPTIc tANK LS 1 SEWER LINES "kaavA — DISPOSAL FLU. OP. Lt of <br /> FOUNDAtION _-L� r AGRICULtUnE WELL N/A OTHER WELL PITSISUMPS _JJ+- <br /> INTENDED USE tY1'E OP WU ; PROOLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Indu01161 b Op&ft eolfnfn d Manteca Die. 61 Well Excavation - Did. of Well Calling U�9 <br /> U DOnteilielPliVit$ t1 t;df&vtll Path 11 ttoey type of Calling_ 1V�s1 Specilicolion$ .- -Al1ri <br /> 1j Puhlld 0 6th&I ,tdt•-;vj 0 Deus DAf)ih of afoul Seat ��,Fl tjs� t2--!� Type of t3rout EL <br /> rJ 4r;t)aMbri Apprde. Depth ❑ I Aft#rn 9UrfIci S61e1 Inslalidd by k1«th r ,frrT FAtE- _—__— <br /> Rwpslr Work ben& 13 type dl Primp H.P. Stet6 Work Dons <br /> Well DHlttietloh [7 Well plsm$Isf Stilling Mitertal Ir Depth <br /> f]epth tiller matartif A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L] REPAIR/ADDITION I I DESTRUCTION G Wo septic system permitted if publie sewer Is <br /> Ivailible within 200 feel.) <br /> Instill&Non vWlf I$FrI —r-t --_-----.--- <br /> Number of ilvliio uAl 1Lre <br /> S•PARGO- ,1t3A XCh$ 6#tet e} inNIt <br /> SEPTIC LANK ;iA41AfkW 60I Vii$A90964 6dLAEVAi'![i 11+91§ACAALkk lto,CAS 9590t <br /> Pico. tAIATMINt PC' � <br /> .r <br /> LEACIONO UNE <br /> f1100t Rb <br /> .t' <br /> swAdE Pit& Nb `fr ,`, ` <br /> 1 1513,1111 <br /> S11Mh3 ' <br /> 1 t <br /> aiSPoSAL PONbt. . <br /> I hetiby t6tlily I1461 I fir:+ ws, And <br /> rutae Int! 111011111804 6 <br /> 110fn$601filt of Ileahll& shell not <br /> Employ Ifiy OWN IA 1 ii ntut g <br /> Mute <br /> eerI11161 Mill fonewifip! mplini!• <br /> flon IIw$ Of C,Nb1fl1j. <br /> The IpplieSM tiiU$ tall (a? Ali t Ulf ! }~Ulla!!. Conipl6!& dfhwihp bri t4velll8 lid6. <br /> x51grts / title: G99t UT Dete: ,Ll�Irl(� <br /> PO" bEf;AI�tMENt UBE ONLY <br /> Applfcetlan ACCepHd by _ _ JJ Data nn, <br /> ~ <br /> Pit of OrOlit 1hlp6cllon by Oltb Final Inspection by 1e <br /> AddlNonit Comendh[$r <br /> Applictnt Pita" all dopi6E'tol AAN JOAQUIN•COUNTY PUBLIC HEALTH 86}1YICS9 <br /> ` f3NV1RONMENTAL ItMALTIf DIVI61011 P1RRJ1IT/SEnvlCBs <br /> . 446 N SAN JOAQUIN, P b DOX 2009, STOCKTON, CA 98201 <br /> INFOFEE AMOUNT bUl5 AMOUNt REMItTEo CASs RECEIVED BY DATE PERMIT No. <br /> f" ,4 x <br />