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y 5: APPLICATION FOR PERMIT „ ^
<br /> ;Y V
<br /> SAN JOAQtJIN CCti7NTY Pt1bI,IC HEALTH.'SSRVICE3
<br /> ENVIAONUFSTAI, AgALTH DIVIdION
<br /> E p 0 sox 2009; ST C,1[1*j CA 95201
<br /> �,• (209) 58 " 1 /
<br /> 'P�iYI'i':�RP��tS3 i,,.�'S R �II01i bAfiE SSUED _ ,,;�
<br /> a => (Comp lert0 ifi TripliGdite) .
<br /> Application ii ttladi iti,id#t11ecd vith tltts Joaquin County *1tAOrdl,d 66hstiudt and/bt,itittail t�vof�k hEYtia deidribdd. Thie
<br /> Application id hi�rdtiy rtlidd � 13rtfi cfisa uid >rotutt fors rioit'
<br /> Joaquin Countfi Publit health Ilii #itdi: rilrtcd,IFo. 549 and i�62 and_the Itulor And Aeairlatidda Of i3r►d
<br /> Job Addrerr tit, ,Lot Sit!/AcreageY
<br /> Owrier'r Nenta 'ww - Addresr Phone
<br /> )(Conliacts Addreft Ltcfnre No Phone
<br /> TYPE OF WELL/PUMP,,gx NEW WELL O WELL REPLACEMENT O, , oE5�RUCtION 0 out or 8ervica Well Ll
<br /> p�
<br /> _:,`.0UM0 wtA1 , rotiitdting Well LjA
<br /> DISTANCE,to,Nmwi, Wtfd'`ANIS SEWER LINES
<br /> 015POSAL FL fL , PROP. LINE
<br /> }
<br /> frOUIVt51lt104, AGRrCUL At W�LL ,�- C1tHEFi WELL, PITS/SUMPS ;
<br /> INTENDED USE , tYGE di=WELL f>R06LEM AkA CON f/iUC[ION SPECIt 1CAfill NS,`> :_
<br /> fl Industrial '" 6,Open Bottom O Manteea Die. Of thfeN Efca3itior JL_W_ Dui. of Well Ceding
<br /> U Dorriertic/Privel8
<br /> 0 Grival Pack'-, , . .. 0 Tie
<br /> cY Typd'of Ca in
<br /> D Public f l bthet g 5pecilicetionr
<br /> O Ddlra 08 Ith'bf thiel eat tYl of Orrsut
<br /> Cl I►ripariorr ° , ,:Approlt. DSptft d EedtSrn 5ui}iic�f s;auf fr�lillfi
<br /> Flepeir Work D6Aa b tvo of Pui H.P, A'titi Wbr i6Rel '
<br /> y a
<br /> W0 Dertruttw. WAN bishwir $"line Nitiefli«i E b0tti `7 *sri 4
<br /> depth'= Pili'ot VAtltrilti
<br /> TYPE Of SEPTIC WORK; .NEW;INSTALLATION D REPAIR/ADDITION O„ DESTRUCTION No reptid ryrlem permitted it public rewar is �
<br /> evAltibib within 300 1660
<br /> Initrtlation VAN terve:I ftiridence =
<br /> Cornrt�Nl�6b1 Other
<br /> Number of Nvina units i Numb&6 "de,66mi ..
<br /> r
<br /> ChirstFit al rbN to A depth 61 S lost
<br /> 16(table depth
<br /> SEPTIC fiANK: L�, >fiypi/FIFfd ;;{ �« CipiditY 'i N"ororhpattridntr
<br /> PKO. YREAVENt PLfi, i `;, .> fulUthod 6f bi =
<br /> rporil �y
<br /> Dirtdnce
<br /> to iNiiritff WeNdurthldti Pr1H{l Lifii
<br /> -• r we#�. sst ,e-,.:e,.._. . ... ._m,•.h_.vs, ...•-.:.,.m., .b•a YVSPo'e'tY..{" ...vr,.,.f.",.x,..pey
<br /> LEACHING LINE tT .No. E Linotf of lih6i ;,
<br /> ''to#ei
<br /> FILTER
<br /> 1110t`f `bltfirrd' ,
<br /> ,
<br /> niireiit' rWAI1
<br /> SEEPAGE Oft I #*to a giiy_ Nun►bir
<br /> SUMPS [) biitahi a tb tlidrert Wrifl Fdirfilleti6it _ ` FrtipartV Lind
<br /> DISPOSAL PONDS Ci
<br /> 1 horstsy certify thit 1 have j3rrparad thlf Ap6bfittioh end that the work will bA doAi Ifs Accdid6nte With San Jodquitt counN brdininder,'dtati fiviir, and �
<br /> ruler and r6ouliti6hi 61164 Sin J6e4ulii Cetrnty
<br /> Home owner Of liceniad agent'i tionaiiturd t6nifii><the following: "I certify thin Ilk the Orfdrmericf of the Work Fib!Which this permit it irruod, r*hull not
<br /> emplo a too foNowi Ih t u6h rm"tit is j6'66c6mi iubidef to Workmen'e dyor`npi/iti 6611 6Wi of Cilif6rnii."Coh0d6tor d hiring of Aub-coritriidliq tignituit ` ' a
<br /> Y sov
<br /> 1i Y fist jsatfoftnindi Of the work}br Whlth this permit 4 irrudd,I tifiAll IM016V 66146nd subjridt to workiiiin'0 to'mpinri-
<br /> tion laver of Cilifo#nii." .
<br /> ` The Applicant*We(cell foe rill r0u{f6d Inipidilotic l btnptats drawing ort teverri Iidi,
<br /> XSigned X_1 Ix .: .. titlr: _ , ., F
<br /> Dite:
<br /> �PO E�Af1=�iENf,USS ONLY
<br /> Application Aedapted 6yii t
<br /> z �t ------�" Datt3 � At
<br /> Are,
<br /> Pit or Grout Intpectl6h by Data "
<br /> Additionrf Com&Antas
<br /> Applicant = ftetufn all 660dd to SAN JOAQUIN dOUK'Ti t PIl$LIC Iit3ALrK tlisltYiC85
<br /> f3Nt►iN sANf:jOA HEALTH 0 gOj16#,019M1T/9SttV1ft8
<br /> 445 N t3AN JOAQUINi p 6 26606 tiTOCxTON+ CA 089thFEE a
<br /> INTO AMOUNT DWArrtOUNT gtMITT B CASH picelvEO BY DATE PERMIT"NO.
<br /> EN 13-711hEv.It A$)
<br /> EH 1.4-20
<br /> .. .............lei
<br /> t . 4,
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