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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COMM PUBLIC HEALTH SERVICES <br /> ENV I RONMXNTAL HEALTH DIVISION <br /> P o Bos 2009, STOCKTON, CA 95201 PA rMEIVT <br /> (209) 46e-3447 Pe c ZI VEQ <br /> APR <br /> (Complete in Triplicate) <br /> Pueu u�N <br /> Appliostion to heretty BNe.to San Joe"ta County for a „rats to construct aad/ar 1patall will This <br /> Jaoalicawo Con to MaePulbto 0001NliSvaioth "aut <br /> Joaquin County Oralaas 10. 549 am 1W sad this Y1SI�^' <br /> s. <br /> Joe Adetase ^y 11. I/�f�sti+�l!- cls, I,et SIse/Acres" <br /> Owner's N » Aft <br /> eft ,7. A AlI77L�_rrr� ►110ey <br /> an <br /> Ca+tractsr Addrts License No. 443_ inose i <br /> Y WELL/ MP: NEW WELL O WILL 1"CEMENT n DESTRUCTION O Out of TOM" all 0i <br /> MP INSTALLATION ❑ SYSTEM REPAIR 09 OTMEN B haai t�Wall <br /> PUO f <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL MTS/SUMPS <br /> INTEN0E0 USE TYPE OF WELL PROSLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl IrldualrlM O Open"nom O Manteca Dia.of WON Excavation Ola.of WON cs*v <br /> 90, aerie/Private O OraoM Pace O Tracy Type of Ces" Spacdicatens <br /> C7 Pubft 11 Other O Ddd DWA of Grow Saes TV"of Gem <br /> CI rrig~ ,Apprise.Depth O Esetem SuAiee Seal Installed by <br /> Repair Wort Done b Two of Pwom � N.►.;� Sue LP ;t <br /> wio DOW"van O IMM DkrnasEr �iai M►terlal a Depth <br /> 000 f'tuw Irtelal a Dep" do <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION VAPAIRIAODITIDNIt Of TRUCTION 11 IN*ISPNC gn$OM if P"We aeww is <br /> eveftie whin 150 Net.l <br /> IrrnbMes wO saner. 11810 oe_ CM1r10tlst_ Dow , <br /> NunMw M idt+♦1NINe: NIX 60 01bedrooms <br /> Chwww of soy an•MOM+of Hear Water ubls dlspth <br /> SEPTIC TANK O TVWMf5 CapstAy No,C, 0MIBwMe <br /> PKG.TREATMINT PLT.❑ Method of bip" <br /> Distance to neefte: WN FounMtion Property Line �{ <br /> i <br /> LEACNNVJ LINE O No.a LargM1 of ane Total"th/auo i <br /> FILTER SED 0 Distance a no~: WM Foundation Propeny Line i <br /> SEEPAGE MTS I 1 Depth Sue Nun+baf <br /> SUMPS ll Distance to neatest: WM Foundation Property Lins <br /> i <br /> DISPOSAL PONDS O <br /> 1 hereby c@Mtl that 1 he"prapand Nib appk~and that the wort"be dons in acCwdance with San Joaquin county otOrAfc $.$1014 laws,and <br /> rules and repul"Wo of IIs San JoWuln Count <br /> Moms owner or licensed agent's aignatury certifies the foso" "I car0tV that in the WormanC4 of tha work for which Mn permit is i$aueA.I ahau not <br /> afnploy any psraon m such m nnN as to beCpM alrbPcl 10 workrrie s compenMton Was of California."CantreclOes hw"Of Wb tOf:tfatthlg signature <br /> certifiesthe lo", m g:"1 CWWV"in hale pMortrence of the work for which this pernit w'eswed.I"A 04 persons subloct to workmen's C0mW04- <br /> tion leave of CaMomis." <br /> The opplkaM must osE! I ta Awod Inspectana.Complete drawing On/Mvvere tads. >. <br /> Signal __ Tile$: t>t'a,4A,i Dan: 9 <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted br Dan <br /> e. <br /> Ph a Grout rspactbn by Data Finer Inspeewn by one <br /> 7-7-17 <br /> Addhional Conrrrnts: <br /> Applicant • Rasura all coptea tot BAN JOAQUIN COUNTY PUBLIC NEALTR SERVICES <br /> ENVIRONMENTAL NZALTN DIVISION PWIIT/BCRVICES <br /> 445 N BAN JOAQUIN, P 0 001 9009, BTUCIITON, CA 90901 <br /> FEI AMOUNT DVI AMOUNT nEMRIO 11ECf Vto tar OAT! PIAMIT NO <br /> INFO <br /> t" <br /> 4A <br />