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i <br /> APPLICATION joit P1;RNIT <br /> SAN .iOAQTIIN COUNTY PUBL:L IIEALTII SERVICES <br /> ENVIRONM&NTAL ILEALTII DIVISION <br /> 1601 E. IIAZ&LTON AVE. . Pjj0Tf CA095tO1_342O <br /> P O BC•R 2009, STC,- JN <br /> ' �lIT IC �1 YfiAR FR2� DATfi IS�IIh� <br /> (Complete In Triplicate) <br /> y t fora rs1t to construct wgni 186ndfor 2 uA thtail e Rules and Reauletkon�Or Rule <br /> Application i■ he:-•b mad,.to <br /> v0ohl SanCJoaQu in Courcy Ori c"a"se Wo. 7 <br /> applleation Is sec in eo+p_ <br /> jmquin County Pub'..c Healt,-, Service. ,�•f., it Lot Siae/Acreaale - <br /> Gtv___.1_..L'Ir .• Lc c /j C-w Ct", <br /> _ :..'. �1tcY %llS3oreaa •. .- _.�.�...:=-Cs:._. Iw PAOna <br /> Owner's NarneG1.`---�- �jZ" p•ione�5 <br /> AQdress.-1-•-��'-�c.�"/...- OESTRUCTI04 U Out of Service Yell O <br /> Coniraaor_ wEtl NEP�ACE tF a Floritorins Yell I] <br /> \EW WCIL L OTHER O <br /> TYPE OFWWELL�PUM P: SYSTEM REFAM ;', <br /> 'UMP iNSTALLATIO4 DISPOSAL FLD. PROP.LINE <br /> _ SEWER ONES -_ -- PITS/SUMPS <br /> - 015AJ. NCE TO NEAREST: FOUNtSEPTIC TANK --- AGRICULTURE WELL _ OTHER WEL —•---- <br /> fOUNUATION _ ---- - <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CJNSTRUCTIUN SPE_CIfIrAT10N5 0 .., <br /> WON Casiri <br /> n Bottom i',Wamrca Die of well E.Carat.>n�_ <br /> (.l IndutlnN Li OPe r.l lav^4 - -- _----------------- SpeclfN:JUMU------ �' <br /> L?Garet Pec► l I ivcv 'tM Tvve of G4wr <br /> f I tla.ws'<f Prolate I Mile Der•+of rpo,l Seat �_--�-- -- <br /> {' Publre ;1 Other i Instaeet(l>r <br /> t 'hrpatron .•- Aptvo.. Depth :EMte•n S.utace Sea Stale Wo-k Done._ <br /> Type of H P._-.._..�-- ___• — <br /> Repair WOr►Donn is f Pmp &eallrs nare:lA1 L L ret!`•. <br /> Wal Destruction C! Well O emeler --- <br /> Ftll•r Maurlal a �'i•tn 1N'.1 <br /> tutted-1 polAt ft's <br /> Rk PA1R:A '«~ <br /> .. I YPE of; apf1C vvJ` 1 e.aitable+.•'M 7t70 <br /> r NLW'NSI AI IAIION i I >OiTit`N Vtl 111UCirph•�I INo seP•:culls••"Ol <br /> ` mtt <br /> Other <br /> lection v..11 solve' Feaidenu.✓I <br /> Co^.mercul <br /> Number of I.edrOOms ';later I"llo depth <br /> Number of awing urwn. �.�t,l <br /> CMraelar of soil to s depth of 3 leer: _ No.Corroom lents <br /> SEPTIC TANK O T", 1MIp r Method of Dtapoaal <br /> PKO.TREATMENT PLT,Ci F 7< .dal on,.— -- P,"Mv Una <br /> Distance to rarest: Wet1- --. <br /> Totallenplh1we _ r <br /> LEACHING LINE Cl No.b length o'IN+"+ - --` ^.i j T Prop""Lira s� <br /> "Gare:[•. wend Foundation S�t�—... — <br /> FILTER BED O.sunce to <br /> N.mtw <br /> :I DePrh _ Property Line <br /> i - SEEPAGE PITS - Foun iaoon -•- I . <br /> SUMPS 11 Distance to"wrest: Will-- <br /> DISPOSAL PONDS C? <br /> Joaquin cowry ordnarKes,sura laws.and <br /> 1 hereby certit/color t heva ore0aren Ihls appiicai.on and that the wor.w.I1 be done in ac_o:danee.r.th San h this, is"Lirld.1 that:not <br /> p Y 1 mbKe of the wort IW vi.fiic «wb•cMtraCnrl0 arprYtura <br /> rules and rpulatrons of the San Jnaquen Cu::"tY <br /> Home Owner pr licensed aQer11's signature Cerlil.es the IOaOwir` "1 CeRd Mat.n the W' 110 wwfrnaet o conlpMba' <br /> subpct to v.ort man's com0enaatNrn ta+.�!Of C�el.forni,s.'•Cnntracrhiring bloc <br /> son in such manner as to becOrnd rm•t is.asulad.I mall emptoY M <br /> employ any par 't cert4y'hat <br /> in the <br /> performance OI the work for r.h.ch ih.s pe <br /> ani/wsthelolbwinp:' <br /> lion laws of California:' on Inverse►Nie <br /> The GPdKant must call fOl ,'faquad'^s'"ctans. ConWiero dawng Date' <br /> _ i <br /> Signed Y f R DfPA MT USE ONLY �r <br /> Date w zIA- <br /> App•,:obw.n AccopteJ DY i <br /> - �- Data <br /> -i-- d_w f.nel InaWctan Dy,-1-M .` <br /> Pit or Grout Inspection by — <br /> Additional Corr"Ants: - — <br /> ee to: Sa.'1 :cequlf. County Putlic a <br /> Heah t <br /> Applicsat - Rerurn i1 coy/ Services, E>rr:remxnul Health Pertait8 orktoe CA 95201 <br /> -= 1601E. 9axeltop Are..•P 0 Box 2009. ►ERAtrt NO. <br /> LK RECEIVED aY DATE <br /> FEE A�40VNI DUE AMC.lNT RCMITTEC CASs' - <br /> 14F0 ^� Wr2•, p p-. <br /> _.�.y �•" <br /> .FN ta:f:ZFV.....i S _ <br />