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p• ig <br /> } <br /> fDPLICATIOX DOR PMWIT <br /> - SAN JOAQUIh COUNTY PUBLIC IIEALTII SERVICES <br /> ENVIRONUiliTAL HEALTH DIVISION <br /> 1601 E. LLAZELTON AVE. , PUDNE (209)408-$420 <br /> P 0 WX 2000, STOCICTON, CA 952QI <br /> :43MM <br /> (COmplate LA Triplicate) <br /> RypullFatlon la herrbr pad■ to brag Joaquin County for a Perm" to cOa@trttct and/or install the work har@lb described. This <br /> aPpaati0q la pada ib ca•pllartee with Sao Joaquin Cou@yy 0rdineace 110. S`9 and LOU awl the Late sad Regulations of Ban <br /> d"quia Cmmtr Public Health garlics@, r t ,1�L- <br /> Job Addisq City y2lQ.d�'�x' Lot Blt@/ACr@ade <br /> I{ <br /> I'LL' Ar% �,I'q,,S k IN L-1- '75Sa11 <br /> [lwrtsra Harm Address O.S3e�15 38 -'C"m 6—CA Phe 416 <br /> L dtni kcne C-s7 <br /> Addrau f.leenu No,HRZ310 Phan f <br /> TYPE OF wELL1P FW WELL 0 WELL REPLAC M04 f1 <br /> DESTRUCTION O out of Lerrlce Yell13- <br /> PUMP INSTALLATIQ n &YSTEM REPAIR O ..OTHEn K . mon rN ;11 13 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,•�,��DISPOSAL FLOC`PRO LINE ,rg <br /> OA <br /> FOUNDATION AGRICULTURE WELL OTHER WELL.SQ_ PITSISUMPS ..� <br /> INTENDED U_S_!_ TYPE OF WELL PROOLEM AREA CONSTRUCTION SPECIFICAT90NS <br /> Cl Irtdualrml Cl Opan Bottom CI Manleca Die.sl Wag F■caealion Die.of WU Ca <br /> f.1 DonwatklPrlrslc �8raael Pack 0 Tfat:y Typs of Caning pv[_ Spoc,lications <br /> l'1 Pubik 11 Other fl Dem Depth of Grad Seal t,! <br /> Type of Orpu <br /> 1 I Irrw■tlon ......Aplxos.Depth I I faelern Surface Bsel Inatatlad by r` <br /> :—T� <br /> Rep*Wwk pats E3 Type of Pum 14.P. AMIALWo D <br /> p Wig Destruction 0 Wei Dbr"Iw gaalina Hatarial i D■yt.h I s r <br /> Vt l- 7tp Depth 111Ler ltat.rioa a Ddpth <br /> TYPE DF SEPTIC WORK: HEW INSTALLATION 1 I ALFAIRIADDITION 1 I DESTRUCTION I I IND wplic eystam p■rrn,ued It public newer Is <br /> •wal"14 Within 200 INI.1 <br /> . Ilytelletion WAss+w: Rulaattea...... Crxevrtprclaf_ all!w <br /> Nuncios/of flwkW units• NwnWr of bedroom <br /> - Characw of aW to a depth of 3 Ieelt Wefw able tlrplh <br /> SEPTIC TANK. 0 Typ0mfg Capacity No.Cw[tpsrtrrrnta <br /> PKG.TREATMENT PLT. Method 01 Dispoad <br /> ViusrNws w rrarsst: Wei Foundation Ptopwny Lby <br /> LEACHING LINE 0 No.6 Length of Wye Total Ienvh/alts <br /> FILTER IMED 0 DIGUr"to mmeal. WIN Foundalion. Frop@rly Lkw <br /> SEEPAGE PITS I I DepthSbs Numbw <br /> SUMPS _0-014tsna to romm 4K.•d Foundeti0n. plop"Lira <br /> OMPOSAL PONDS 0 <br /> I ha.eby Cantly that 1 haw prepared.We 9011ca1104 and that pre wane kip be done N aCCospsnca wish San Joaquin county adinanGe,sols Laws,and <br /> ruI■e and rapulations of the Sa+t Joaquin Cee..ity <br /> Born@ owrut ar acans■d■pmt's N$nttturs cenifi f>, "I cefuly thar in the perlormsnCs of the work for whkh this parnit Is laeu@d,I shat not <br /> c npf as thlov e 1fiowinq:son In ffuw,gIV he as to etc}�1 ;p workman's ppntpaneatlu:4wr c1 Calilanla."Conuscta'�1 hkinp or sub•contuctinp lionatws <br /> t kI tluI Atm&%14 pt C-4 V401k fot whkh this peach Is issued.I shall empky peraoaa subject to workman's <br /> don taws of S.Wifanla�=.. 11,!•` sOn+psnss• <br /> The @p+�sct ;ot,n cel fa exittr tlbry.Ca�p1: �swlnp on rswlse aide. SLG �c�tJrc,l' M ��n <br /> S1p+tad Title: <br /> .. Date: <br /> FOR DEPARTfYtENT Use ONLY <br /> Appliatio+t Aleepleel ,� Onto Ana <br /> ►h w Grout Inap"*%btf ljc E„ Firtal Inafs+ctibn bye <br /> �:..:..�..�. flea-...�„ <br /> Additional COrrwmnts: <br /> Fppllowf llstttti aLt @oyies fol ger♦ Jwquis C*Aty PubLLe Health <br /> goryiae@. rAviroopentel wealth Persit/Set*'Ices <br /> 1601 I. Rasaltaa Aye.. P 0 Max 2009. BtoakUm. CA 93701 <br /> 0 AMOUNT PUS AAtOVNT Atmirflo CxSH RECEIVED aY GATE PEAld11'ND. <br /> • <br /> IN f}N IIItY,its al <br /> eN tr•y <br />