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ENVIRONMENTAL UEALTet DIVIS Otl
<br /> 446 N =1 JOAQUIN, PHO' (209)48�`3AIb_,�Qs�
<br /> P O BOX 2003, STOCK%OK, CA 952O--{ --"-' -
<br /> PERMIT EX41 RES 1 YEAR PRnM DATE; T43f1V.!t1//1� yI �/� �'�
<br /> :-,Mplete in Triplicate)
<br /> Application it berelty rads Seo Joeguin county fm a pernit to construct end/or Install the ,it tereln de+crlr.T--nll-
<br /> applleatlon it aWa 1n aryl'-nce with Snn Jeagoin County Drdlesece Ne. 549 and 1862 anp the Rules sod Regulations of Sen
<br /> Jaspuin County Publio Health IMrvlcee.
<br /> Q !pp AddrNe _.__vr� A//N �— i,�yA_.'_r //� city ,ems_— Lot S//t se/Acreage _
<br /> Ovwwi s Name�L_JXLby_r--J_�_�+Adr�i,..c C `3 c�� �JL� Phone J
<br /> l ! I CGn11acla .l Addle%,_[,��2/ t %I�f l,.chat Noo..29: "''f%T Phone
<br /> 5^ TYPE Or WELL/PUMP: NEW WELL ❑ WELL RIP'AGEMENT fl DESTRUCTION ❑Out of Service Well
<br /> k PUMP INSTALLATION 0 SYSTEM REPAIR -1OTHER ❑ Monitoring Well
<br /> DISTANCE TO NEARF_ST: SEPTIC TANK SEwrl II-)CE ____ O.SPOSAL FLO._ PROP. UUE
<br /> _ ?C'JNDA710N _AGRICULTURE'NELL __ OTHER WFI.t.__ PITS/SUMPS
<br /> NTtNOEO USE _rYPE OF WELL PROBLEM ARIA CONSTRUCTION SPECIFICATIONS a
<br /> 3 (1 Indu.tna ❑l Opon Burton ❑Mard00 Du.01 Wan EAcrvatbn- —_�,�f I Wall Caging _ n
<br /> R h 1 Do stle/Ppyste ❑ GuvN Peck l7 Tracy Type o1,CasmO _ q�Qci_:
<br /> 1 Puhhe 1.1 O M Il Del•F chi of C_mn Beal �/!h)"yep,
<br /> ' 1 1 Inlpthon __Able.. 04plh h Ebur Surface Swl Installed ! Run _
<br /> Repair Work Done ❑ Tt,pe of Pump _� :. __ —� •
<br /> Wait N
<br /> DINctlon ❑ Will.U4mltcr __ i vu Sna Valerie] a Deptt \
<br /> Depth _ y1119:Natart.l 1 Depth
<br /> TYPE OF SEP7IC WORK: i:fN'.INS rnLLATjnN I I ',EPAI0AD0MON p( DESTRUCTION 1 I (Rd is l wdhln 210INt.) '•p Nave.4 `
<br /> Installation wit Nrve: RealOence - Commerc4 _ 111191 \
<br /> Humps?of LNngi.its:.L..Num.Mr of Nd,romn
<br /> Chl,NRN r of NR lois depth of D fN0�_ �d Jl Lni1_N' Water IabM QafNh \
<br /> SEPT'C TANK L3 Type/Mi9 `H}.�aa.LA7C CePe-.ty.—_._ No.Crsngar ft __ 1
<br /> FK 3 TREATMENT PLT.❑ - Method of EJ)tposal
<br /> t�rt��r r
<br /> Distance to Mihai Well(KZ)�yvFoundation 11!22 Property OIIa
<br /> LEACHING LINE- : A( No. B I,anBth 01 life �' p Tnu:
<br /> F:i.`.EA BED CI Distance to M4:ert: Well'yj rtamobr on err- Nopetry LIMj.P�J^
<br /> /./ ,/'
<br /> t Sf'_FF.GE PITS I+d 1 Depths 3ife y�/lin/.,^.J Nurn'»r
<br /> I _
<br /> Ili'.APS Merest:t0 Mer ': Wall/,Qiv�Found.,ch SFT Property LIMN
<br /> p19`OSSL PONOS 1:1
<br /> 1 hsuby century that I haw,prsplled this application and that IM work will be done in accordeu,nwith San Jwdoin count,erdiMneU,ateN 4we..and
<br /> .we and rf91rlatlDtre of Ifw Rn.Jos 1.n county
<br /> T
<br /> .4."owe.,or licensed spent tail re certifies thisioiowaPB."I certify that In the padormanca of the s¢d ler we
<br /> hn this Permit 4 Weed.1 abs net'
<br /> employ any Person in suet,mercer ac to become subleet to workman',cf
<br /> empan+alion Lives of C614ornla." antraztefa 1,41.9 a
<br /> romwb•eenYaelfnS aynatdra
<br /> Corti the following:"1 comity that Sr.tM Mflormanee of:M',crk lot which this uremit is issued I"G employ"clause subject to towkiell nom "
<br /> tion LO.'Of Calilotri
<br /> f V M1
<br /> f. x hj 3 y ;• TM.9pghnt..at call lcr Ar uir•.yt'nxpec Wn+. Compleu rmm
<br /> distend on r aide.
<br /> I fined X_ '/ll' •e:00 . TiM:- „6va �' Data:
<br /> 1 ' FOR DEPARTMENT USE ONLY
<br /> App:ie+tlorl Accepted by - - Dau r _Ahaa
<br /> �1 .S
<br /> Pit w O-+ot Inyretkn b't -__.--Dete___ Fira1 Insgetion by Dttas; '
<br /> S
<br /> .1. Additional Com,,-P%! •---
<br /> 'f�l,. ADPllernt - Return &;l copies to: San Joatvih County public Health service.
<br /> iavironteontal Health Permit/tlervices
<br /> 445 N Nen Joaquin, D 4 Pot 2009, 9tkn, CA 95201
<br /> AMOUNT DOE AMOUNt REMITTED CEN[D eY DAT[ PUAOT'NO.
<br /> 5j"' t artt5fa,nn.hrau
<br /> an
<br /> til I.
<br /> 1
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<br /> Y V nv`y'1lV J M
<br /> t+tia:. 5 � i Oyu
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<br /> 1.
<br /> ' 1 � 3F LS�,;•�Gt�{ . ,z�s ,,eve
<br /> �.S',���°;i�'�r.Jt' kL,.h,i niti+'T*;�i�a..',SW"v.�th�'i.�.u{�,vxRYy.•$,t � ..i`u�Y,.a..1�..11��f'R'Y� ".d'.".'�„J La4E:n�si,r�.ilhb 3..r.1re "::i ;?
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