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<br /> APPLICATION Foil PERMIT
<br /> SAN .T�)nc�[rIN rniJN'1Y PUDLIC .l3SALTIi ST•.11VICES -
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<br /> xN V I R0T aEENTAI. HEALTH b I V I S I ON
<br /> 44!') N SAN ,IOAQUINS: PHONE (209)46R-3420 l_lt
<br /> P 0 ROP. 2009, STOCKTON r CA 95201 a
<br /> (t-*nrr.pl(--i.,-, in Triplicate) �
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<br /> Aypllnatinn is harelry cele to nen .I Aq+ In C •rn!r Tnr n Pat'"Pat'" to eanatruit and/nr inlr.atl the wort hrY.((K�'7it
<br /> aSTlleation if *Pete in COVItsnet vIth f•-119fn f:atnt� Ordinance ad. '1+r4 and 1662 Vo the Rulra aM It t.+!1 ne of feu } tW ,. ?•'
<br /> Josquin County Public Health ElerYlcen. f it s
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<br /> �7 r at Sls�lAcrref• ._. �? f'r
<br /> .Job.AdAreas.��� ;4-S.+•ti��L.�...J
<br /> D+wrset'a#lame CH 1s R0, _ +a w _ Ad!ryt�� __ a_ Pnvn+
<br /> Conti be li..},>]dL,l_]rei-a P-L," y
<br /> TYPE OF WELLIPWAP'. NEW WELL WELL REPLACEMFNT CT DESTRUCTION U put Dr Sarvice yell ;0 '. ';fit"
<br /> MJMP INSTALI-AYM! i.J SYSTEM REPAIR 0pTH{A ❑ ilanl tenni Yell E7 ',i , I
<br /> DISTANCE NEAREST; SEPTIC TANK __ _ SEWER LINES DISPOSAL FLO. PROP, LINF aA
<br /> si
<br /> NDATlQN _ AGRICULTURE WELL OTHtA WELL r'S
<br /> INTENDED USE TYPE OF w[ii—- M AREA CONSTRUCTION SP 5
<br /> Ll Induftrxal G Open Bottom - La Manteca sCavalirin Oie.of WOO Ging
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<br /> gpaeitrcata+;t - f' ,
<br /> CI pomeuitlPr}vau C7 Gray+I Pack' t Z TI•t Typo of tau _
<br /> I'I Public f'T Olher _---I Delta Depth of Groul Sets TV"of Grout
<br /> I}Irrigation �:, f)nttth t i Es►leen SurlRA Boal lnafalled by
<br /> Repair Wore, Type of Pump — --- H.P, State,worst Oona_ }
<br /> Pats Dxtttxtibn Ca WaN i)iarYtater Aosl,ina IYteriaf L DeytA Q a.>t .{.ie,
<br /> Piller material Ji'Dayth '
<br /> Depth.- -
<br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIRlAODITION 4 1 DESTRUCTION I o WPuC system-yamnud of pubbe sewer is. '' €
<br /> evadable,"Al"2W fael.l
<br /> lAstallsskln w*sets Fleefd 4441 CDrnn.etr.°af Other
<br /> �4� t'��. FI Un�{1r c ;}t- ,+•.r jt_ ,....-.«.. � v i �' a 1�L't� A.,y }d. �$�� ��P+: }6� ,.. ' �y,�� ��1 +
<br /> • �.Yte�if■def I'M
<br /> yMfq t }x''DaP� if�t....r..- NbCe+irwRer++tf r a_fi�.F �4,�
<br /> lea.TkEA th-r-"I �t• 11'!
<br /> } j7!7rSy�f"1tr'`{ie,'`,"tE DktarSCa to Well re,tY. t ,i fit ,-_ (�7` �' c �, �; _ '� -re
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<br /> 3iri`iAi' t�+m-rLksr-e a -r,, ,� w '_�,
<br /> LEACHING,649.,ti et Cl No.E Length of liner. Taia1>rfigthlalte .,
<br /> FILTER BEO r}k a I C.l Diftar+to to-rmatl: Well -- Foundetioh'.r,.,:, ..�' Propeny Lkw
<br /> SEEPAGE pIT3' _ t i Oept1 4 Number
<br /> SUMPS LI Distanre In nrarrat` Well - ._ Pewnda►len: r.��. hoo"Lina,.:-•- --- . �L .j,
<br /> DISPOSAL PONDS Q �7 �#
<br /> x I Cerli that t he!N preparetl this epul!Car•M,and that ilia wodt wilt lM done.k itecerdance,vAth$■n Joa4u1R CWRIy arrlmenC.s,lute law -and ► _ .�'A rti..
<br /> rul�M and regulations of the Sah Joao•tth Cmmty Lill 37y'
<br /> Noma oweret or lkar+ud eg nve fionasure certifee the following:'•I certify Ilial in thi`prMorrrunee of its worts few whkh this parrr+t h i.aued.I ahafl not 1 t;i
<br /> emCbY My p��h M streh errnnar as to bocorne aubt■ct Ia workmen's ebmpenutbn-lewa of,C■Rfeirnia."Conlraeloet hking or sub-contraethrg signature
<br /> . h rflpt�@+t.R' ":;r•!^`J.'.)-r.r!+i!a frr•.!iN!•,�h,.•�..-...tea n!tt.5 wa1M1�f7r wh#Fi tlt1A1MGt"fl t�iiltttl.I ehllt�mp{oYPiift+hi lud}ee.r to,.•nrtr•,e•n't mea.
<br /> iron laws of afiirx,,A,. a
<br /> The,apPlka a calf eM sets i t�rA+e. Comrtfeu drawing ra0 fief•.'
<br /> siglr�._,e Tltt.: DaUI
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<br /> -a R DBPARTNICNT USE ONLY
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<br /> Applieailon Accept"by - -_Ir.4., k !Hata..1�►�� 4...�.� Anr
<br /> Ph.m Grout Inflssctbn by _ _ nut. Finn�Itlipeel7ort by bat,
<br /> • AddhfohllCo!nrr.ente: ......�`'•.l�'..�` ..���$� ..✓r, _- _ N'I�d'�i� � Er
<br /> i rL'q't yr� ,-' I as:. t f t. 1 r x1]}E� N1
<br /> 1 ! APplirdnt. - Arttir :nl+t lire ,-Y. b-n J"A'iit t.tj-Crnt rl L$ s'u613a-#l1i�NiJB�'f''JlSnn NI Itr '
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<br /> pial AtAtiu r�Mtlar r } :rrr!tt�rY1'CCi »� e_ I� BATEEj }`f l r r �r+ 1113I '� } 1 'r i + �
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