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APPLICATION
<br /> ~" SAN JOAQUIN C(HIM PUBLIC HEALTH SERVICES "Lz' F
<br /> HNVIRONMTAI.'HEALTH.DIVISION 'f '7
<br /> 445 N SAH JOAQUIN; ;"NONE'�(209)468 3410 '
<br /> P O BOX,2009; STOCSTONE O, S52O1
<br /> 'r'. n x }r ! a• sryb y��la*i+r s' ra .rN
<br /> (Complete in.'-,Triplicate)ns v r; ;rrr {v. tit y�J it
<br /> h ' , Sc hereby aside,to Bua Joaquin Couaty for a'pirmit Lo conatruat aad/or'•lnetall the trorl hetern dseoribed rTltia vS / } /'
<br /> Sa nada in'conliance with Eaa Joaquin Countjr ord3n nw Ao SL4 end 1862 and Lha]iltlea and paw•t•tiana o1'!S•an �r 1 Y{ a
<br /> Public Haaith Ser►1Paa.' l- x r /r ,y,' { y _- •','y r_' .r"r {, � �. ,
<br /> .,rlAroar �� --- �/�p�
<br /> City;
<br /> Let else
<br /> /Acreage
<br /> .�,,�r'o A?nr;,a' �a✓.r�4�tri frf�:rf�� AddrassTl�/p� -��� �'?hona `� r'' �{a � v'� Y'� a
<br /> P�
<br /> " .,. �� `:i/ ,;,. ,, - .';.F _ •�1'' '4 3 E.'.� *.,r'+� � -e`,.r�"'!'t, 4k;*`d' St �7'
<br /> "• „ -i .LLQ. Andress �i ! `ir7��4' License Nti .5 �.Phone
<br /> TY t/PUMP NEW WELL C3 WELL REPLACEMENT:[1 DESTRUCTION o out of 8eswsce
<br /> "PUMP.INSTALLIITION q SYS EM;REPAIR C]f 07NER esOPitorlAS ifrli
<br /> TO NEAAEST''5EPTIC TANK SEWER LINES pESPOSAL FLD PpOP LINE�_
<br /> FOUNDATION 'AGRICULTURE,.YELL,' "- `'OTHER WELL' PI SlSUrdP$'
<br /> - t ,r 5's'"r- + s•N Jrx'tyr �yy �P3 r Y^" +'
<br /> '.'.hlp*D USE, ; TYPE OF WELL :PROBLEM AREA CON57RUC71ON SFECFFiCATiONS � A � s;
<br /> i dual rrl C3 Open Bonom ❑Merttew Ota of-Well Excavation, ilia ttr wa1 Ctsdf p ,x C L � `t" i
<br />' t .Ipe,,a:clPriveto ,.1 Gravel Pack C7 Tracy-, a ' 7Ype of f`eoI xz " zv
<br /> y n9 SpfClNoitiorsa �1^"t :
<br /> �... ? ;
<br /> 1-1 Other f 7 Darts Depth of,Grout Suf _.��, Jypahott Grout 'l�'�F� 1 �' }
<br /> f1 11m Approve Depih''uI I Eestan y Surface Sea4lnudhd '
<br /> Rs} bona t3 Type of Pum H P
<br /> p _Slate Work Done
<br /> Wt .....:n:cro1 O ;.WaE Dianaster 8aalins ilaterta2'i Depth aux ` r x isti7i
<br /> a .Depth,: - - d Tiller Materlal•i Depth . .,.. ,+-•.t ,a.},r.:., �., avy
<br /> T r:. "r S !'TIC WORK NEW INSTALLATION I I REPAIRJAODsTION OESTRUCTION l k:rNo septic system pemtiIw if pttpie eerMt le wr y� y=y h£Y
<br /> avast"wttWn 2W fast f ya,t i 1 j_ f" '.0
<br /> k', }
<br /> [✓ h:
<br /> ron U serve: .Retudertce Comm
<br /> ..� a cleOther
<br /> i"f•
<br /> .Number of badraoma "' c.r' i�;;u .° •� >t ti,,, `^ .a ' '`ro ,`�¢r.�+�` 'a4 F,�,t'''£� Er ."' r n�`�, 4'd'
<br /> Cr r• ., c r wa to a dopth of 3 feel: !" ; WaTer fih11; Y ry ' i tg
<br /> + +: c # t�'
<br /> SEi'TIC a .'G' Type/Mfel Lr:—^'---- O Y 's No CpmpSRrRMtt% t a+°. .� f a R�1 ?•r
<br /> PKG. FdT?I-T.d 3 i ° f,Aethad of ClepOaal t3 styc r' yr ��
<br /> Distance to nearest:,:: Well Foundation Property.LMe r ° r {} j �y •.
<br /> L.r�r,i. C LINE No b Length of lines!
<br /> r Tasl knpttalske ti fes- } , 9
<br /> SED t L1' Dlrtance to nearest Wetl FounAat�n_ `r"�T' PropMTy '' �
<br /> t`S^tH,.. is ..
<br /> Nambaf'
<br /> eU LI Dutana to nearest '` Wel!-' Foundation Prapeny Lau
<br /> Df DS :r Fr G sof 1 f i } /a 4
<br /> I hs r- 1•;hitt I Flava praparedd this aC�**tion and that the we k will be done inreccordance with San Joaquin county ordlnaneea'Mets laws ttls+d�`}9,�p`zc
<br /> ruin. y i,�01 ataa of the San J y.: :rU k{ ,
<br /> $1tv -,wr or licensed'speM'e ligMtur1 c rtirm the,f0Aowinq .I cortify thaf'iri the perfarmance'of the vKrkt fof-whkh f}Na . . + '"a x r# A.
<br /> pertnit a kelwd I tthell t1p1, d
<br /> e ^Y t roan M such Insnnar as to bect me wbject to workmen s carnpe1134 Mn laws of Cakif6rnta.''COn rsctoYe Mrlrtp a nub co+itfectM+4 ttlpnetYrt
<br /> c :'11 foNowirq I i rStTyr tfsir in the performance of the work for wh eh this permit n teeued !shell employ Wroons tub*t to warkrh6n s Corf,peneR ', -, �:`
<br /> i of California Tj":%.: -
<br /> A,. ant hwst cell fa eN - inspaetions.Compiela drawl On rsvene side �� �` za , t e=:'� ;•� c t�„r-,r ,aw
<br /> to
<br /> y'�,r,.!1._._,._ 71110 - Dale'S.5 i,�7 �/ 5•+ryq.1,r,. rr•,�r'se� Zy�:. ,ys
<br /> `FOR OEPAiYMENT UBF �Z{ r'
<br /> by Date 7 7 Z�}� �1t0r ik c _
<br /> Prt Ir""ction by Da,e Final Inapect°on b x 3 t wt
<br /> y Ot to
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<br /> 1 r. Crri+.-rwnq. -r.. r s " �` v'�' i+Jf,'<°i a3">h'� "`v +.+•s
<br /> ,plicrni - Return all copies for San Jca;u3a Coanty Pttbllc Health'Servicee ,', t
<br /> Env3roameatal Hnalth Permit/t3ervices ° l ,� � s '� ��� �°'�' :s�i� r
<br /> 445 h�Sanr Joaqu tp ..P O 9mt'2pp$- Btka CA 85201
<br /> ' - : . ..- - E',••a.: }.a kr .r � �.-. 55 r k. F ,rte 3 :?' P�}'
<br /> AMOUNT DUE AMOUNT REMITTED r ;; RECEIVED.0Y-; DATE :� 'nPERMIT NO'"'" r s ; t+ ;ti.y-r F
<br /> V CASH
<br /> .EK,}N faCV. yJ
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<br /> r • z. f 5'it�,i tgr- �1$r ."' +,eS'�+,°'�kirtr a..q� $ 'r "r
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