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1 <br /> I'p1Zt'br.na <br /> FaxK7Transmittal Memo 7672 ktlep°" f°°"' -5 1h' <br /> r9b - 1� � "U --- — - From <br /> tbmp*ny CrunPanv (/J jj" <br /> [.oudea LDUben flee Cnrpa <br /> Fax/ _Tal. LXIT phon.a fat I T.fepna7 ,�O[J`sr7 J <br /> CMerwna org-0OsnrDf �Return El Can By P dk P <br /> DnPft*A. ElAPPLICITTON <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI S <br /> ENVIRONMENTAL REALTH DIVISION <br /> l 445 K SAN JQAQUIN, PHONE (209)46$-342 <br /> P O 803 2009, STOCKTON, CA 95201 <br /> DATE ISO I <br /> (Complete in Triplicate) <br /> Application is hcroby 3a4o to Baa Joeaqulo County for a permit to construct and/or lnsta 11 ]he work herein deacr bed This <br /> spplicatiob to rade in caP;plianca vith San J"qutn tawny Ordinance No 549 and 1662 arsd tJSe Rule* wad Reav2atlona of San <br /> JoaqulD County tvbllc health BarvSee• <br /> Job Address 950 Industrial Way city Stockton Lot i.e/Acre-a,, <br /> Mohr—Fry Ranches C/o Je ry1 I=ry 20933 +-3808 <br /> Dwn.r.Name Marfan Mohr Fry Address 12609 North West Lane/Lo I C,„o„a <br /> 1900 Powell Street <br /> eonuacto Levine-Fricke Addicis License No Phone -652-Ii$ <br /> TYPE OF WELLIPUMP NEW WELL U WELL REPLACEMENT fl DESTAU TION 0 out of 6etwlc* troll O <br /> �laR apllppm{T�epre PUMP INSTALLATION ❑ SYSTEM REPAIR Cl THER ❑ t4onito-Ina Well U <br /> JOl DIIS7ANCF TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 lndvatnal ❑Open Bottom ❑Manteca Ora of Well E.csvation Ou o1 Well Ceding <br /> rl Donaei-01`11vsts Ll Gravot Pack 0 T,scv Type of Csang I Specifycation$ <br /> f I Publlc Il Other fT 0411e Depth of Grout Sul Type of Grout T <br /> I I lrrpatlon _Apfuo. Depth I I Eastern Surtaco Saul Inateited by <br /> Repair work Done 0 Type of Pump HP Stat•Wors Don — 11 <br /> Well Destruction Cl Won Oiarneter aealind Notcrl.l i Depth ,V_1 <br /> Depth Filler itaterial k Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION i I REPAIR(ADDITION I 1 DESTRUCTION I t IND sapfic system p*rmmod I pili.C —W is Zr <br /> wsa4a>ie rthrn 200 fest I t7r <br /> Inrtapatlon wkp corm Reerdenu_ Corrvnarclol— Other <br /> Nurnbar o1 Ihrino un,% — Number of b*droone <br /> Cherecter of sop to a Oeoth of 1 tut Watir table depth <br /> SEPTIC TANK 0 TyoelMfo Cspec ty No Comportments +Cp <br /> PKG TREATMENT PLT ❑ K401tiod of Disposal <br /> Distance to neatest Well Foundauon Pfopeny Line <br /> LEACHING LINE 0 No i Length of 1 nu Toisl Iengtlr/atte <br /> FILTER BED O Dgtanee to nosiest Well Foundatror, Ptopeny LAs <br /> SEEPAGE PITS I I Depth —SL1- Numbat- <br /> SUMPS Ll Olslence to n"leot Wall Foundation Propany L n* <br /> DISPOSAL PONDS O <br /> I hereby e*rtrty that I naw prepared[hrs spphestlon and that the Wolk wR be dans in accordance w th San Jo OutA county ordinances silts Isw* and <br /> rules end r*g.Aeuon*of the Sin Joaquin County <br /> Homo Owner of hcanMd agent a signature con f-ag the following 1 candy that In the pertormence of the work lot which thio Derma as uued I shall not <br /> *rnploy any person to such"new►s to become*ubfect to workman a compensation tows of Celdclime Conti ictor a hNino or aub�onirectmg wonoture <br /> candies the following 9 certify Choi in the p4dormanc■of the work for which this parmn is issued I than ompfoy parsons wblect to workman.compenso <br /> tlon laws of Callfomla" <br /> The sPp6ea t must cell Ior 0 eq""d Intpecttons Compete diewino on refverse redo <br /> 6lgnadTitleDole <br /> Yc�roY dw d rs !f ) Sl L <br /> Is AAL& <br /> FOR DEPARTMENT USE ONLY Applkelbn Accoplsd by Dns 455 Aree <br /> Ph or Grout Inapectton by Dat* Flnat Inspection by Oats <br /> Additional Comrnente }}�� <br /> Applicant - Return ell copies to San Joaquin County Public health ServItOli <br /> finvlroonenL•3 HePernServices ZaJ <br /> auih . 0ea5 it JP O B 709 �AYY] <br /> ,tkn CA 9520 <br /> FEE AMOUNT DUE AMOUNT Itt MITT to H ECEIVED evwTC PERMrt No <br /> INFO <br /> rKIt24WV rrwar W- 8a � 37}23 1 93 -ppb <br /> Ettau <br />