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APPLICATION FOIL PERMIT <br /> t <br /> r„ SA.Y JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> glIVIIi01171FNTAI, ILEALTR DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> a„ ne.gXlT +I_.Xv1RES 1 YEAR FROM DATE 1SSM <br /> (Complute SD Triplicate) <br /> .yropilc.uoa I.1$ neu eD Incaact to San once vlth Eau,J auifor <br /> Co ttyr00roin1n .construct 9 &Ad 1862 aeo the Rules herein <br /> a" idintlatlone of B This <br /> Jpsyuf0 County Public Neaith 5...Is... , <br /> alv I.tfYaa Lot Slte/Acreall <br /> JOD AdOnv <br /> Access <br /> 9 Phone . <br /> ,a,�.��If Lrterse rvD�,�rs! Pnene <br /> C0MOc10r, AOorefS <br /> TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT Il DESTRUCTION Ci Out oT 9eev1N cell <br /> PUMP INSTALLATION 7 SYSTEM REPAIR 11 <br /> DTHFR G Nwll WrtrlO Well [] <br /> a� DISPOSAL FLD.__ PROP. LINE <br /> DISTANCE TO NEAREST SEPTIC TANK SEWED LINES <br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Qu. of WON Ca.inp <br /> 11 mdusIFUR U u. a <br /> Ocwn Bottom i7 Msnteo Dof Wall Ea •011on Sabbuflan, <br /> tam T,pe of C•,mg <br /> U Domestlp 1i C Orr"Pace t I Ti Type of Grout <br /> ❑Public Il DIM, LJ Data (),,in or Grout Seal __ <br /> ri!".Edon —Apl.ua. DIPth Cl Eastern Sun%te Sam mataaed by <br /> Repan Work Done ❑ Tea at Pump _-- H P, Stals Wort Done_ <br /> - Sealtm material A Depth <br /> WON Deet. ct7 O WON Claimed, 1111er Naterlal A DepeE <br /> Oeptn__ <br /> EYP(OF SEPiID WONN'. NEW INSTALLATION 0 REPAIR/AOL1tT10N DESTRUCTION G 1.140161101 cV'^^2mma11i:luso d public aw+r Ia <br /> ImuNtbn vdll aarw: Reslpenc._ COMM11011 r Other 'eNE— <br /> NYmWr of Ewing unit$:— Number of bedrooms <br /> Woe,tabu depth <br /> CMrrote,el sop to•" t"of 7 INC_ No.Cornpnmenu <br /> SEPTIC TANK Elt1b7_0 TMly ype: t.p•mn <br /> Method of Diylaul <br /> I� Pfi TREATMENT PLT.❑ a n <br /> D7eenee m nee.ea: Wall Foundation pro v Line <br /> LEACHING LINE /K No.b Length of lines _ f X / _ Toul bnpinhiee �fw/ <br /> FILTER BED CI COMM,to mane: Well <br /> Founpsuan +ddb F NopenY Line <br /> a. <br /> SEEPAGE PITS I I Depth Sire__-- NPnIMr, <br /> SUMPS LI Dianna to harass Wag FOundlpan.­ Properly Lim <br /> DISPOSAL PONDS ❑ <br /> I",say sanity that I nava prepared this application and that the wort w.0 CO Duna m aicmdanca wren$•n Joaquin rounW Ordinances.furl byre. end <br /> (Vida and regulation,of Ina Sin Joaquin CountyI shal t <br /> Home thyme(pr licensed age",,ap`teun Cemla,IM 1040wmg "I CO-101 Intl m the pad Cont Vlmnnte OI IM act Wnlrn 1MF perms it itlaWp. Actemploy any 00,40,in such Marine,.a to bottom,sublep to wmKman'a co,noense"yaw+01 Caulynn."CmuOemi$hiring ar 400 comnsunp Hpneure <br /> se'ldlea the logo—i 'I cemly that m In,Penormance of In.won 101 wlheh IMa pom11�.ewoJ,1 shall employ Pierson,ablest to workman's COrrlall <br /> _ 11.I.M Of(ALlOrnla... <br /> The Wcant"I Cell lo,aN'diUfpscb ria.CbmD'.ea pnwm0 Tun Ishew I'd- <br /> C? <br /> pe11 <br /> greed ' <br /> �\ 9 DEPARTMENT USE ONLY <br /> � Ane <br /> Application Accepted by ar�Aa.—'LTJ 'c — Dur �- ' <br /> Date <br /> Pit m G,WT inspection DY Data_ final IneV.CtiOm O, <br /> ew Adphlonel Comments <br /> Appllaaot - Ae Luro all Prone tar SNI JOAQUIN COUNTY PUBLIC IISeLTII SERVICES <br /> F.YYI:7011NENTAL IIEALTH CIVISION PdANIT/SERVICES <br /> 425 N SAN JOAQUIN. P O box .DON, SMICKTUN, CA 95201 <br /> ZFEE _— 1"i I R[C VED ev Da+[ I[RMI'NO <br /> RAMO!UN�TD�017 AMOW,i mfynl[D 4 <br /> a+. <br />