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�vENVIROtt11ENTAL HEALTH --VIS;ON -_- ��—p--
<br /> 440 N SAY JOAQUIN, _^HONfi`` ,,9)468- a��-__,�&_q.✓�___-
<br /> P O BOX 2003, STOCSTOX+CA 9Pi20,t, apMWj EX4IRF3 T YEAR FROM DATE:ISSU tIMT
<br /> (-•mplete in Triplicate)'' o► n► a-i -
<br /> Applleatlon it her4by aade to Sao Joaquin County fn, a permit to conetruet and/or Ireton the work hsraln daanrlee'--hili
<br /> s"Itcatim Lir
<br /> De llrt Health Daryl cascoe,Ph elan Joagalnn Co
<br /> unty Prdlnance Ne. 549 and 1862 .n9 the Rule. acid ReNLtlore of San
<br /> Jowufn
<br /> job Address _ `,r `] .'o , ��.LY/)L Gry_—__—_— Lot 9LLe/Acreage _
<br /> Owner'.Nione AMrms 3�� — phone
<br /> ,1 Cwbatla �l�t+l --Atldress�s1i .%L�-�dfC�CGCLKenae ho ��r-' -�Phone • r
<br /> Y a TYPE 0,''.VELI./PUMP: NEW WELL ❑ WFLL REPL.CEMENT El DESTRUCTION ❑W[ of Service Well
<br /> OTHER ❑
<br /> Menitorltld Il ET
<br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 1
<br /> r 'S DISTANCE TO NEAREST: SEPTIC.TANK SENrl LOOS __-_-- DISPOSAL FLD._ PROP.LINE
<br /> ?O'JNDATION AGPICULTURE WELL __ OTHER WESh_— PITS/SUMPS v
<br /> 5 (I r ft n.sl T NT LADED USE _!YPE Of WCL. PROBLEM AniA CONSTRUCTION SPECIFICATIONS ft e v
<br /> Wen Calling0lnlu tnN ❑ Open Button ❑Mamaca Die.rl Well Exce"Ilori
<br /> ❑GrwPaJ TucY of Cetina_ e
<br /> I 0" r
<br /> I'Pointe 1:1 Othu Cl Dell. _
<br /> Com,
<br /> �PIWjlwt
<br /> ��F4Is, Y1 ,l I I Initiation _Apprua, pawn i. Ee.lat. S.dage Saul Imnlled byQi--E/- ---
<br /> Repair Work Done L) T••r of Pump 4 __
<br /> -- — � 4
<br /> WNI Destruction t" ion ❑ Way Uumatrr •"t%lttg Material a Depth
<br /> +5trt ..: Yil19y IYtertal C Depth ir £R
<br /> Origin v
<br /> _ —
<br /> TYPE OF SCP•IC WORK: iJ£N'INSfnLLAT ICN 9FF'AlOACCITION O'i:RUCTION I I (Ne rplk mum U.wiblK MW4 r
<br /> 1, aWil),l:J within w,XW(NI.I /Y
<br /> - �• ,,I Inuaaetwn wlp rive: AaNdenn L Corr+vrda'_ Char
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<br /> Numbe.of living.trifle—if -Nowhiv of bedlromn
<br /> r,. ChAreetat of wM 164 depth of S fest:__ � �» . taw depth
<br /> SEPT'C TANK ❑' TY Ilii) " '[e1r�LL�f�CSZC CID .1Y NoNo. CarnpentMnn
<br /> dzl't r) FK-J.TREATMENT PLT.❑ — Method of D'poaal
<br /> ������i
<br /> Dlaunca 10 MI l: Wit Foundation O�— Property Line
<br /> A�
<br /> ND LIKE NoLan0th idt �Totat
<br /> FIL7EA BED Cl Onta.nur to MnWellfFuondbvon 4&1 � Property Line fQ2i__��f-
<br /> .rr-r_
<br /> _-�-
<br /> r� 1 SEf FADE PITS �I 1 Depth f Sin -L lm/ NVrrlber_;-
<br /> !1
<br /> uW
<br /> SEEFA FII Dunce to rtrrrl: WNI L' Fendar�an F� Prom Lm r i
<br /> ' DISSrOSAL PONDS 17 "
<br /> la_ At,'t I hereby CbMiN that I howl pint thea application and IA4t IM work will W done In accot0anea with Sen JMdldn ceur.ry erNMneu,atfN loot,Del
<br /> ruNe and regu411DM of the Ran Joeddin Cwoty
<br /> 'Nana cntrrc a Ifeenrlf apmfa afpmnurr Miott" the ioNewnW'"I eertfN that;n the pertormanca of IM•ti2 for v.grKh thN petrt4t V lewd I ahag Al I
<br /> employ any petition in such manner as to become abject to worimer,'a companunon b"of Ca111drNa."CnnV¢tafa Ntlnp a aub-eonYatNNtg algMtun
<br /> '> con,Kwa the lolowing:"I certity tbal e'.the pDrjo,n,l of:M work for which IN,uumlt is iquW,I that;amply penal abject to wbrkm 's a0rnpwu
<br /> IOwe,of CailfaiNa."
<br /> Aik TNogNkallt mtut can for All r un-,f!nape,[bas. Completed awing on nwrr tide. , ,
<br /> 9 V.} signed 9 it:'moi _
<br /> t f� Yine:. .tdd..+, a _ Dau: 'J
<br /> C�1 f rte 1Qilt } - FOR DEPARTMENT USE ONLY
<br /> App:katbn Accepted by — Dna_ /
<br /> �C) A..Dat _ Flro:Mgctbn by
<br /> yT 1 i Pit or G- t Initial G! --__ DHeT
<br /> AddltbMl --.—
<br /> Comn..nu: ----
<br /> Health
<br /> Pil
<br /> t ! w Applicant - MOLtT aJl coPiae to: go entot viroewHean jo.toin lth Permtt/Srvvtenevlcee
<br /> 445 N ben Joequlni P 0 Boa 8009, 9tku, CA 93201
<br /> R I f[ DUF AAIOUNy REMITTED CDV[D FY OATE IERRtiT'ND.
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