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:SAN utC?AQUIN cOUN ` `pI)aLIC S$ALTH SbRVIC.ES <br /> Erre 11Oxy05WxAL (ALTS DIVISION <br /> 445 N SAH JOAQUIN, PRONE (308)488 3430 R E C `!v F 0 <br /> P O EOZ 2009s STOCXTW, CA 95201 ,f A N I a !93- <br /> Epp c <br /> � (Cam 1#�s'�_.___ <br /> 1? eta to Triplicate) ------- <br /> �pp1=c•ttoo it Isgr+by srda.to $.s+ Joaquin County Cor a <br /> yplication Ir Taube in coagliar,ca riot 6.p Joaqula Catrntty a dIAAACO No, 3li9�anQp1$eS2aan4 thetAU eltule� aadr A.tul►slon�of <br /> .loaquia Cauaty Public lfealth 9srvicee. 1'7!e <br /> �,�! San <br /> I Job At}d�.1r –L�.1.,� '`� 4 <br /> City Got 8trc/Acrey9CafJ <br /> Owna►'a Noma , g,� Addrass F <br /> f' Phone <br /> ------------ <br /> �->r C4nfratta r ` Addr�s>1 S S <br /> TYRE Of WELL/p�Mp., N WEII G l tcentt No. � 'f Plsans <br /> Pump llq�TRL�r1TfOH G Wf:lt REPLACEMENT !'! DESTRUCTION Out of Oarylet tralZ G7 <br /> DISTAD NC( TO NEAREST; SEPTIC ANx SYSTEM AEPAiR Q OT}�FA CO) >'tonitarin� wel� C] <br /> --�-- $EWI R LIMES r.,.. �– . DISPOSAL FLO. <br /> F4uND�, IOfr AGAICULTl1AE WELL — OTMEA W, PROP. LINE <br /> IIvTENOEG V5E TYPE QF WELL L A CONSTAUCTION SPFr:IFICAT1ONs PITBIStJMPs. <br /> PR4$LI:M ARE <br /> 0 lndustrisl 0 Span t3florn <br /> r C1 0001Mrlicipriwt; ClGre p ' 0 Test© Mrnto,co, Die. 4f Wail tX41yown <br /> +roI of Woo Ceelnq <br /> rick <br /> 1 1'1 Fabric I Y Typo 41 Cesinp_ <br /> i:l Dtliar T1 Dfit>! -----'-'---~--•��• SacNk�ticn� <br /> j u,r Depth q lGrouf Seel Typo d ¢rout <br /> k t i lrri r ...,.AppioN. Oop1A I I Enr/rn AV $vMeci 8:n1 Inet;Natl aiy <br /> Repslt Work pone L] Type of P <br /> Well Dertnrttlon H,P.. arils Work Done <br /> Walt Diertjatd W fH�3ti>; 14terial 1 JD+pth t <br /> �� <br /> Dspth �i n. l likteriol'i D+pth ' <br /> i TY�PE�O, SEvTIC WORK: NE+,N]IVP 7ALLATj()N 1'I- AEPAIRIApOtTlp#� 1 I pEBTAUC710N I 1 {Na gpgc rystern psrmiltad R puS"(ps:y i I <br /> InaralIvion will serol: Ptti¢;nsa Cn av; ahle within 200 Ttr1;1 ; <br /> rnrr►arclsl..� Other ^� <br /> Number of Lwknp ynhe: T Numbs►of -- -- <br /> t>e4 oome <br /> Choroorer of colt to a d.pth at 3 tjit: - <br /> SEPTiC TANK ❑ 7ypa/jr411f Water Iabi/depth <br /> F90. TAEATMENI PLT. Cl !I CapeCity .No. Co+rit�►tlftents <br /> Distance 10 naereetr well Method of Dlrpow <br /> P <br /> 111 ...,... ovhdollon— Property lint <br /> LEACHING LINE A } Na. i 1len9th sl liner <br /> j FILTER 6ED '3 Gl DiraunFe Ia +ti41�e�t: wall ]`01111 14(1011/111140 <br /> Foundation Plnparty Llrte <br /> SEEPAGE PITS 1 G.pt11 <br /> ' >SUMPS K Stie `�' NurnWt <br /> L1 Dieter;• to aeerertt Well,�,______._ foundation <br /> 011POSAL PONDS ❑ Property Lira <br /> I hereby certh IMt I hov;psrparad'thlr Application ;nd Ihet the work will ba dons In sCcortfrtnce with S/n Joipufn nt <br /> rules and reguldlonl of the Sen Joo�uln t%captr 90u y ordinances, stale 1iws, end <br /> Home owner 4r licensed sgant'a t�4t—ja oan:111a the following: "I comity thN 1n trio,W10rmsnCs of the work for Which this rrnh <br /> empby enY pers4n In such fbonner of to become subitep Io woikmaa'a componlation laws of Cs111ornis."Conit4cloes hiilnq Of sutrtontraalnp sipnatvra <br /> csrtlli"rho, foAowtn : "I Oonll P* N ksuad. 1;hiir nor <br /> : Y that in the p+rlormrrsca df the week for anion 04 parmlt f$Ipuad,I shaft employ persona Au 60 Ib work <br /> Iron tarry vi Galllcrn .� l <br /> Tho applicant mu;l ;Oil for on raqurrkf in.pee .caro. CCrnptire drawing en reveres Side. rMn'e companao <br /> –P Sipnod I <br /> Title: r Q <br /> 1 FOR DEPARTMENY USI ONLY <br /> Applir.;tion Accepted by <br /> Pk of Q►4ut ins Dale_ Are action by Date�' ' �'�3 <br /> --- ----�. 11001rup.ction by Dete -3 <br /> A3ditlanal Comrrwntr: <br /> h - _ <br /> Applicant • Return ill cbalea to; ea. <br /> vices <br /> l ; vit•ocaeotal b•.itb f;'armlt/9orrloejosqula County Pul'110 116411th a <br /> 446 H dao J904 ia, P 0 Sox 9009, btkn, CA 95201 ;!q,d d <br /> iNfC Amouhr 0 6 A� <br /> OUNt IttMlt'tYp <br /> • --�....��Q, /� <br /> C " Y <br /> DATE" ' <br /> / y 'f3fABH At [ <br /> 1n 11=4 uuY PEAMIT NO, <br /> 14K <br /> GI314,5 <br />