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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALVICES�� <br /> ENVIRONMENTAL HEALTH 1IV1'$el <br /> 445PNSAN JOAQUIN, PHONE <br /> 0 BOX 2009, STOC%TOX, .9[AAg'��t3420 <br /> PERMIT E%PIRES 1 YEAR FROM rFAA; <br /> (Complete in Tr1p11cat�pJ1 Y v v c5(pt- <br /> Application is hereby sade,ce Spliance ae Joaquin County for a Parrott to comtruct a YYY Tf le <br /> application is wee in comvith San Joaquin County Ordinance are. 549 and 1862 and t e <br /> Jeequtt. County Public Bealth SarTleea. <br /> O ?S dJSAN ��j'� fhv Lnt�y 11e/Acy.a . <br /> Job Addrw. 6,91,1 /p "r/l/ <br /> Dwnei F Norma 1 �" Ad�t l; •Y�� P b <br /> � � v/iG SC/tJ WAY <br /> CO 1 eclat Addmaa ^ UCeme Nom`'-��3 PMw <br /> TYPE OF WELL/PUMP: NEW WILL 0 WELL REPLACEMENT n DESTRUCTION Ll Out of 8411" W-12 11 - <br /> PUMP INSTALLATION 0 SYSTEM.REPAIR O OTHER O Nonit'nrtng Well EI <br /> DISTANCE TO NEAR.ST: SEPTIC TANK SEWER LINES __ DISPOSAL FLD._ PROP.LINE <br /> FOUNDATION _._ AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C Industrial [TOW Bonom 04;r Dia.of WFR Eaceeetiorn Du.of WON Calling <br /> C)Oarwalic/Priv.'. 0 Gnval Pacts 0 Tracy Type of(.damp__ SpCv ,r <br /> 19✓:Joie (71OIN, fl Dal,& Depth of Grout!bat nt(1A^Rr�,`, <br /> IIIrrgstbn _.Apprm.Depth 1 East.,- Sudsce Seal Inn&Wd by R�VLT� <br /> Ron&Work. Doha C Type of Fump H P. SI+u Weh Dona_ <br /> WallDeetructlon 0 Won Diameter SeallN Nathaniel i Imyth <br /> Depth_ Piller Haterlal A Depth SAN fnMlTIN Cr`iUNTY <br /> jq <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I INo wyyr� {L �e <br /> avaiuhY 11 - <br /> v, <br /> :nstswtion will wive: Reaidenrpa_ Comnwrcial �Other s <br /> byrtnbar of Eving w9pic.M.&- Number of bedleerlhe <br /> ! L _ W11M IaWa bpfh 1 <br /> Chapala of toll In a depth of 7 feet:�D!/Cli - �- j <br /> SEPTIC TANK. )9..Type/Mfg r;=-,:v4J pecilY •Carnpamai <br /> PKG.-TREATMENT PLT.0 / Method ofwDllpese <br /> Diwence to rwe.M: '••JailFeurdetbn /5 PrtgenY Uses <br /> LEACHING LINE 0 No.b Length ni:kr• _ T�ul�ingWaite > <br /> _ fol rERpEU- - v V1. Distance to n.^....t. wo�'?: FonMetgn per— PNZI Line <br /> i SEEPAGE PITS I 1 Depth Sin Nun YrDepth - <br /> J SUMPS LI Oliag noo to rr:.reeF Woo Foundation ,:-opwf Lim ". <br /> DISPOSAL 'CROS 0 I <br /> i 1 hotels,certifytat I Mw prepared Ins,app&etion and INt-he wort will be done to accordance wth Son Joaquin County ordlNNwan <br /> ns,issue lows,and <br /> rola <br /> and ngula=of the San Joaquin County ' <br /> - Meme owner a handed Agent,.ilgwmn anility the IeAowng."1 Certify that In the parlor ti of the wort for yAtwh this permit N iwued.1 minae rot <br /> employ any parson in ouch'ware,sat to necoms wbject to workman's compensation Larry, California."Contractor'$hiring a 8.11) rntnethp 6091.ors <br /> emir'the l000.OV:"I Lenity,that in the performance of the work for whuh thrs perat is assured,I sNil employ poraono subject n workmp s comwnaa-. <br /> flow,lows of Came-"." <br /> The stink t mmu fw ag mequkad i .CCm Aw; owing on <br /> Signed lt//J//--f Tn4: Dau: ��—'�-/ � '. <br /> � DEPART RUSE ONLY } / <br /> Appecallon Accepted by ""— Date � ,. y Arty <br /> art,w Orad INpectk by Data Final Inspection by r„EQKA tA2.1rg's) 0.Ic: <br /> -Additional CommsnM: <br /> Applicant - Return all.topica to: San Joaquin County Public Health Services <br /> Savo roeaee Lal Kealth Paer.lOth <br /> HSM Sao Jeagnia, P no. <br /> 2n0 Boa SOOB, Sete, CA e5901 <br /> IN O MOUNT AWE AMOUNT REMITTED CASH Ritcamo W - OAT[ MRMIT MO. <br /> f I /93 15 <br /> . tv f1H IaR r/ea <br /> -.•rwddTi3 '2.4. 'tel^ +r. 't e ,�. » +. � 5..•.�xtrn:�:.-a. .rtf:arum..L?•s..r$Vi''Arima"31y:t°'nt' ,g5erl..'f¢ .e1t'.:+.,...__..'. <br />