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�AIYPOICATION l (� <br /> SAN .IUAQUIN COUNTY PUBLIC HEALTH31yjys lfi. C <br /> ENVIRONMENTAL HEALTH DIVISI �)_}-F ----- <br /> 495 N SAN JOAQUIN, PHONE <br /> "(!209)4 %VgtP1R <br /> P O HOE 2009, STOCKTOPE T EXPIRES i,� <br /> (Complete in Triplicate) <br /> Application to hereby mode to San .1"4ain County for a pe•mit to conetrurt and/or install the wort herein described. ni- <br /> a1N11"tions Sa ode in cz piisnc. Ylth San Joaquin County 0rdlnance No. 549 and 1862 and the Rules and RelfuLUona of San <br /> •Iv4u1n Cawty�PPubllic�Health 9erelcee. p <br /> i' Jib Add,ew 1-i_3 _U_� -�C-p-�_- Stu/Aereaae , �L <br /> 8 l� �� <br /> ' Owneis Nene rnV lY/�J �"/ S Addicts _req ����Q Phone <br /> . Con't tot G//GLdC.`' Adtlless.'OY � dfILF_S]L Lmense Nn rel-y_'1Tyl�' pre <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL Rt P•.ACEMENT f1 DESTRUCTION L1 Out kow"lna V 11 ❑ <br /> PUMP INSTALLATION G SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC„TANK SEWER LINES _ _ DISPOSAL FLD.__ PROP. LINE <br /> FOONDATION - AGRICULTURE WELL -_- OTHER WELL PITS/SUMPS <br /> ZINTENDED USE TYPE OF WEU. pROeLEM AREA CONSTRUCTION SPECIFICATIONS el WON CeaNq Et, <br /> A fl Indvat"al ❑Open Rorcn ❑Msntaca Dia.of Will'E.cevm.nn_ �rV <br /> 1 7 DomEelkl Prlvw ❑Daniel Pool, <br /> Tncy Type01 Citing .-. Speitfk/allu ns W <br /> I'I Public I:1 Other <br /> Delta Depth of Groin Sam p_ � MINT <br /> ;� r legatgn _-APMOa. Depth i I Eastern SurfM:A Soul Instilled W <br /> _.� Repair Work Dona U Type of Pump _-_ H•P.--------- State Wer:Om._RECEIVED <br /> lues j <br /> Well D"INwbn ❑ Wall Diarneer <br /> Selling Matarlal i Depth- -�sTM tOrT <br /> Dlvin Hoer Notarial a 'xrpth OUNIY <br /> r ]Rr 7 TYPE OF SEPTIC WORK: NEW INSTALLATION I Rf PA:RIADDITION DESTf1UCTION I aV.'Iwpl E.pRIIIE.'1� UIHE^LTN DIYIoI N <br /> 1 DtN1V,:Yl�ltlw/�Yd^�4rJ R <br /> ,,Ey x .•I. Ituta4ux wN furor: Resiinra� Comtnecorn, GOter <br /> Y <br /> 1� I NumDm'of IFAn9 unlu:.L_ Nambar o1 Iedrooms _Wmar tate both <br /> �`r S - Ch P,or wR l0 a depth of 11001: ��tJ�TA/_�.. No. n <br /> SEPTIC TANK ❑ Type/Mfg ---- "•„""y - 'wylnrnene <br /> 9 <br /> tai \ PY.O.TRPA � <br /> �M4T PLT.❑ Method of Disposal <br /> Distance to restful WaitFoundellon_-_- PrnPenY Line_ 4 <br /> Tf Total len th/size <br /> LEACHING LINE `� No.1.lyrgth of Ikea'__- / ♦f,>- <br /> FILT£R SED ❑ Dista'nc'e two n'aaansi: :,Well aae�_� Fovnbtion-lJ f7� Property LIM. _fes i <br /> SEEPAGE PITS 1 I Depth �.�5^is a ! �j � J ] <br /> !!ll SUMPS t,/ Number <br /> ONwnea to nNNml Wall Az'� Foundation_ZtZ-Prop*i Lim.�f�- <br /> J'" I_._._... ... <br /> DISPOSAL PONDS ❑ <br /> 1 hem C1RiN that I huva p'kparad Ines application and that the work will be done in aCeordence with San JeaOvin CQUMY OrdiMM.H.eAM larva, eM <br /> _ .nNoo SM rapulatbna of the San:"Quin Cot cy thin In tM PAnrmance Olin.won ler which this pen tit Is kauM.1 WR nol <br /> Homisrrrenar d Ikanaa0 agenYa Npelun r�rtifkt ire Iotowm0:"I cavity <br /> 4 <br /> SPIV any parson In such manner es w begorus"Died to workman'{camPenemlon Item of California.'Contresm�ns tub wt m�wwkman'bi ScemPanM <br /> cwwoa ilia Ic9ow'irp:"I canift,that In IM Performance oft"wwk tot welch this Peunn Is bauod.I shall omPloY Pe IaQ <br /> flan Isere of California." <br /> 'aE M eppncArt trent cat for W r IN Pec' ae.COmymo dI.An9 un reyeM r <br /> T <br /> /fky�0 _ Tln. _L. iµ. _ Data: G� -- <br /> Sigred y YY f <br /> (F / FOR DEPARTMENT USE ONL'f <br /> Data ria <br /> .Applkstbn Accaptad nY --'v <br /> -- Dee-_---- Fbsi In:Pecuon Dara <br /> I 'Pit w DIaJI Inel,rxlkn by, _ � <br /> Additional GMvrenti: - <br /> APrL'.cant - Return all coPiee MSun rr]ntwnte Countuealthvpermit/Serviceevlcee <br /> \.� 45 N Sae bAquIn. P 0 Roe 2009, Stun, OA 95201 <br /> V AMOUNT DUE �AMCJNTITTED II RFtIVlR aV DATEeERMR'NO. <br /> FEEINFO <br /> .............. ...........,w.,,,..•...,taw.ora.uwrr.'.w.i.rw'd::WMk+dtl�lt+'Y' <br /> A �, •.,c`NWMiRIlENM'°NM�wsuurwWrrala ...r+ •..^•"• ••'....»_.. <br /> W , <br />