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APPLICATION FOR pE1tMIT <br /> SI:N .10 ENUVIIEONMkN TAL iLEALTII DDTY PU13LIC IVTH ISION VICES <br /> 1601 E. IIAZEL1'ON AVE. , pNONE (2095201_5420 <br /> 1, 0 DOR 2009, STOCKTON, <br /> hXP311E� 1 YEAR FR'"' DATE ISSUls'Q <br /> YSRMlZiComp l,te in Triplicate) <br /> tea to .-wvtruct w01/or Install the vork herein dL1 orbl�of Her, <br /> e.tn Sap Joaquin County for • T" c,''0 ce Ro. 5\v •N 1962fhd the Mles and R. <br /> Application L hereby Md / <br /> apPll catlop 1, Bade in edel', era with Ben Joaquin CowtY <br /> yqufn Comty PUDlIe Health eervicl s. _ pot II.cmcrlw <br /> J <br /> r - C,I. <br /> Joe Address �lc�='t <br /> PNM <br /> %� .- / may va► (��J�r^'t.tom _______-_._— r ( <br /> Owlet's M1ny I- � _ <br /> f Ji.ZI�/ / f JJ— .e•ar Nr��l "Tine <br /> Contractor ( PLd,e1>_I - r.[..Lrt�.i�' <br /> V+EL'. HE nLACirtkN� DESTRUCTION l Out or Service Kell (7 <br /> TYPE OF WELL+F MP , NEW WELL J OTHER ❑ frohltorin8 Well <br /> PUMP INSTALLATION C SYSTEM REPAIR L PROP, LINE __ <br /> SEWER LINES -_ _—_— DISPOSAL FLO._—_ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ OTHER WELL PITSISUMPS <br /> FOUNDATION __-- AGRICULTURE"ELL __ <br /> INTEN::EO USE TYPE OF WELL PROBLEM AHEA C_O_N_ -1 R:ICTION SPECIFICATIONS_ Ow of Well Cal g _ <br /> 1 Inusvyl EJ Dom BORdm O Mameu Du of Von E.uwtan,____—__.- <br /> f p__ SWUIKatd <br /> f I Dorestef Puw4 ❑Growl Pact ❑ T Trace vw o C.em T,Ps all Grnut <br /> C,Pebhc it OINI 11 Delta Depth Of G.cul Seal _ __— <br /> I I ingnyn __A,,.,.. Depth I I EHlarn Suo",Saul Irmdl4d by y <br /> Repair Work Don ❑ Type of Pump H P.___.-- --- State Work Don_ <br /> Well Oeelnchon O Wen Diameter Sed1r18 MRUrI&l L D.-pth <br /> Depth_ Pt liar Material A Ilep:h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPMHIADOITION I I DESTRUCTION I I Ievacada wmm�ZOO IrstlNO"I".f,Slem m—'Ied d puW,[wwar Is <br /> Ins4nnidn vieraarw: Reentrance_ Commercial ✓ Other r� <br /> Number of NVIg unite_ Number Of bdrooms <br /> CN,w.of son to•depth of 7 itis,- War*,table depth p <br /> SEPTIC TANKO Typo/Mfg No.Compartments <br /> PRO.TREATMENT PLL 0 l Method of Disposal <br /> Distance to name Wan /'tjr-}^ Foundation . ProperlyPropedy Lim <br /> LEACHING LINE Cl No.b Length of lines 1 Total lawh/Hee L- r <br /> FILTER BED 1:1 Distance to martial:- Wan I:ir`��'a Foundation.�y_ o•openv Line <br /> SEEPAGE PITS I 1 Depth _ .p ' + Sue /y _ NumWr <br /> 2 <br /> SUMPS IJ Distance to manal: Wait _--rifoundal. Fire, LKIs ra;L - 1 <br /> DISPOSAL PONDS D <br /> I NrabY Coadk,-that I haw prepared this applpaoon and that the work wdl be done In accordance w.tn$.T.IoaOukl count,Ndnancn•state Minn.end <br /> Nle,and repu41Kw or IN San Joaou.n County <br /> Hpma dinner w licensed agent's ai nam.MitW 1N lonpwmg.-I Tandy INt in The Miormdfce all the went for wAKh this pare(is y1Md•1 thrill hat <br /> amplov sly person in such manna as 10 become,wormer to workman•co:noenaa0on few,of CalAurniaCe Mnetoi s hiring or sub,contract"V slpnatws <br /> camel"thefosowtno:'T Candy that 01N wormame of IN wa6.fn,~this ppR41 y nomad,I"If ampaY palsons aubleu IQ xror\man's comWnaa- <br /> tiOn 4"of California.- <br /> The <br /> alifornia"The appaniRMIItans Cmet. <br /> SKed mTitle. <br /> on n/,fwrse sWo. / <br /> Dow <br /> [\1� OR'DEEPARTMENT USE ONLY �, 9 <br /> AArppBea:lon Accepted by C1�1o�G r�-O'�� >`�`4p��'a�•4 Data_____ Ane / 7 <br /> l7t Or Grout InpacNn b,�44bdte[=C� Final Napectwn by Date y <br /> Addltlelral CaeMynta: <br /> Applieant - Satu all copies to: San Joaquin County Public Health <br /> Services, fIlty1rensental Health rerrlt/Servlces <br /> 1601 S. Harteltoo Ave.. P 0 Bo. 2009, Stockton, CA 95201 <br /> IMft A1MOUNTDUE AMOUNT REMT1EO C^tH PECfIVtD B, I DATEr PERMIT NO <br /> ('y- <br /> RAr <br />