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<br /> ,.y '' • APPLICATION FOR PERMIT
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<br /> SAN
<br /> JOA UIN
<br /> ' Q COUNT' PU"�.I C
<br /> ? irk ENVIR HEALTII S$RVICSS a ��`•
<br /> ONYENT41, +h7ALT$ D I V I S ION '
<br /> :'k IrR kr 445 N SAN JOAQUIN7 -$LINE (209)468-3420
<br /> P O BOK 2009, STOCKTON, CA 95201PR
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<br /> APP"c'MON to plicate)
<br /> ayillication ie IlWebl stsda a °Joaquin County for a perait to construct and/or Install
<br /> Jeagvla COnoty Public r th Seirvices. flan Jaaqula Cougtr Ordlnanee Ifo. 544 end 1862 and the Rules aadeflep.latiribedone of Baas � '•
<br /> Job Adoreu _.� / / 4F A/44111 Plf
<br /> n' C.orr4�iK
<br /> C-'C--L�o-t llia.�c/A
<br /> Owrrc Name Address C.ifht ;Icreye
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<br /> Phone 73i. 3'��'
<br /> c` ' ConIIaclor E/7 ,rr
<br /> Address Fb /79
<br /> pj/Mp: License me.
<br /> O 7 Phone
<br /> 1� �y, qr M e•y' y+ NEW WEL WELL REiLACEMENT fl DESTRUCTION' Out at rr ee r
<br /> .. PUMP INSTALLATION OTyE O si Well SYSTEM REPAIR Q Moalt:ari
<br /> DISTANCE TO NEARESTL SEPTIC TANK [j
<br /> a suit s' FOUNDATION SEWEA LINES
<br /> 1 12
<br /> DISPOSAL FLD.�__ PROP.LINE ; fi ' id a r
<br /> }� AGRICULTURE WELL a '
<br /> ��_ OTHER WELL PIT SUMPS
<br /> P'w ' rY# ,+ ' �INTENDIED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> k F'o '-t�3Lr "3` ladtr"triN "�^'-- /
<br /> t� !1; "a`�, ' `�Donteitk/Privele r, © 1 Bortam a M8 ytece
<br /> RE 1 PirbNt
<br /> . SDirA.of WelEceralionPeck �G
<br /> SOpVa.oof W�taeolnCaring aCaring°C qype of CasingOttw fDNta T
<br /> I i Irt Dporout Sabi ,
<br /> Aptn x. h Sf in7ldapWWDOf1 T ] TWO of PxrsType al Greu
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<br /> DaqueNph ¢�I�yyM Dlpn.'or �r Seslia8 Material a Depth
<br /> S re wo Done_ tiY�./ * E
<br /> Depth 1111er Mater'al i Depth" �" y' k
<br /> TYPE OF SEPTIC WORK .
<br /> HEW INSTALLATION I I REPAIR1AAD171Qk[I DESTRUCTION I k INc fepfk fy"!am
<br /> .r� g r' .!t _ '� S-, - ;"= •..�.nroutillift - pefrnitlsd 11 PubI1Cr -
<br /> �f y�l twrL$rj t�gr1 ,r `'IIJ i of �W :R` d' Corwrurclat._ Othiw^ f" svadebN withM 2D0 hal i } t;ryy�`.
<br /> r 1p �1 bedr
<br /> a ui� ? t P } ..^+p trr,ln. Nvrnber of
<br /> V. ,� q Deme
<br /> Lev M` '�f {y f' .r CflMaCtet of bE to a depth a/S fast: i .k
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<br /> SEPTIC TANK ";, I O Type%Mfp skater tah4 depth ;_n
<br /> r€°� rife ,�'PKG TREATM#tdT Csp"ehY f«<r E
<br /> h + nor ❑ - + _ _ --�� No.Cornpertmenta
<br /> �k w* a € ,_(2 i ; thud of D r' f
<br /> r yy t � < d v c e; n r �s' r s .+,DI"tai,ea to rteara"t: peep Foundation IappoaN c`
<br /> r T err r r rT sr . Prop"Lhne f��� �
<br /> LE/1Cf:INI's LINE c + Cl No.i I enptti of linea _. 1 3aT )l
<br /> FILTER BEDt Total 4ngtl,l"I:e
<br /> mak''r r q r r ^` O.• Dlstano"to nlereat:
<br /> `r Wall Foundation P10POrty Line
<br /> SEEPAGE PITS-.:-i",
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<br /> �')s:I , s SUMPS r LI Dlete ICs tD Num
<br /> fyyf" x f ,r;is;a°DISPOSAL PONDS F rwrgt. Wap Foundation _^ Prpperty Lbla
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<br /> t r,�iy sri�; *• ':I hereby certify thei f hews prepared this s
<br /> cul""arld►eptdatlpn"M 4he Stn {a tion and Iha1 the work will be done In accordance w;lh Ban J
<br /> "' ty '
<br /> oagvlh county ordl anew."rats leru,
<br /> Horne ownor w fEcen"ed ape,11`s iiWlelu»prtlfies tl,a following:"!cuts that in the performance of the worts
<br /> fat which this d :! 3 ';
<br /> }"+cots in each rneanar as to become"vbjact to worMmen'a a mparnatba Owe of Wlsforrda."Contreat w hie p"t 'b i shall not r
<br /> ;r S ' c✓ 4'�yq; s,.,;tort 4w"M ollawk t, t ert!7y that In dN perfo�mrnce of the work iw which this
<br /> renis is issued, 4f1 Or walxntrasfir,p tlgnatw" r '` '✓r ~
<br /> The -a .' s+e vad,I shell smINOY persona Wbjset I*wod,mul a son,p +s"26"
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<br /> z ° sap for repuirsd hapectbn".Campine d•a an
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<br /> r ti ? E j r'I R DEPARTMENT USE ONLY r r
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<br /> %�"Psctlan Date
<br /> �cll;�.Fine I by
<br /> nlpectf0r: Cats /i/ �G�
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<br /> `E, x'} ek ,.•t. APplicaet - Beturn all copies to; Baa J0agaln County Pub11e Hoaltb Services
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<br /> 9arlronteeatal Bea114 Permit/Sarvicea
<br /> [ 448 N tlaa Joaquin, P R
<br /> ! Box 9008, Etta, t7A 88401• + r_r
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<br /> N a AMOUNT DthF AMWNT ItE1NITTED RECENED W DATE
<br /> LowCASH PER
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