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<br /> ►Inti IIilAOIN COONTY 111411t1ic, a nf,`PI1 r110,IIVl(,h;il
<br /> KNV E RONMENrl'AI, HEA1,1+11 l]1 V I N I ON
<br /> ' 4IMN ,K)AWN) V1101:
<br /> ll fi IJOX I11f1i,1(I, 1IT()tll011m (:'A IIIwoI
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<br /> ! � II I pal lipj# f �'I� i I .illll I q �l; fi , , I I 1 Ifni{ ! I: i I iRlfi Ilz III. #
<br /> Jl+li Ailllihii _...AJ ) ���.. 1. rY �»•1i ( I}J/iflAil' I rr�Ai r sdrj! Dz.:
<br /> Ownor's Name _L4-..-/L...�.d-4C--...-IeC,I.,I�4 .C__. Ac7rl,«a
<br /> rl 7N./�Dr.�i7F r!>•- pts
<br /> Conbaclar _/ I_O1�_F_Jt1�P� A�dr�ss �, y! f.ra/7_.,.. _ l,rrr,e H,
<br /> WGLLJIIIJMP N(W WCLI�CI. --• �W%1011 fi(i,jAi,{r•U+tI i' bi!,1111)CTICiN t� colt of LSerylcn veli i`,l .
<br /> PUMP INSTALt.ATION i", Sl'S"f:'. t±t 1':IR OTF CII HonSLDring Well f�
<br /> 11f��t,tVEl Til tlkA���i; §FPi1L iAtJb .,-,.,_....- filWlft 1i11f4 �i1!tl'rlfli+{ FF13 .. _... NfiiilF I,Ifi� .,,,_ „
<br /> ....,.,..Y....�_�,_,,._ ... PPu►#QAIIo►1 -----.__---. ai;Itir.l,i.rf+nf yrFIF grttf:Il wftf ..._Pli:ii�11MP4 J � �;
<br /> INTWIttl VSE iyPl OF WELL PhOill(MAIIIA CC)N5titt1Clt0Nr I'F(IFWO)ONS`Y
<br /> fl Indushlel — f,l Open nmlom niece fT•a-rrl Wall I,,r.aval.nn {ha of Well Cestnrl
<br /> i f 1 DomashClPt+sile C! Gurot Pack (I Tracy Type of Cas-- ._...._-__..__.._,_ ._ Specifications
<br /> if C!Public fi Other I I Delta Depth nt G'o„r Seat Type of Group
<br /> c, I I In Ryation __Aplitom. Depth I 1 Eastern Surface Se„1 lost allad b.,
<br /> Repeit Work Done {] Type of Pump _ II P. _ _ $Ina Work Done
<br /> Wall Destruction 0 N:atf Ownetor _ _ Ecaling Materia, i 1cp•t. _
<br /> Dapth Filler Hat?r:a: i Depth
<br /> 11 TYPE OF SEPYI C,1h'gRl(, NEW INSTAL LATtOh RLP4[R/A00r?,0ti, , Li!_ti IFI11CT1ON i r Itch acphC avatem permitted d p„nlrc sewer y ,+
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<br /> !I 4nataliation will serve: Residence`/ Commercial_ //Gli,e, a�+anab,e w,tn,n:00 feet 1
<br /> I Number of living units:._,_.,,.. Number of bedrooms
<br /> oil Charocfer nI soil to a depth of 3 to-tt: .�AA1 �.t+ � Wato, [able dep,.h_
<br /> F SEPTIC TANK O Type/Mfg _ Cana uty,_�i�C�n - Na. Companments �-
<br /> t PKG.TREATMENT PLT.n Merv'd of Diarlosal
<br /> — Distance to nea,est, Well _"7 FDundal,on..Z-4_ Property Line
<br /> i LEACHING LINEYE'I�o.6 Length of lines �-,-'-.fes' _ Total:angsh/site- l'c'
<br /> FILTER BED ;_I Distance to neiratt: Well t"-"'t_ Fou--cation Property tine
<br /> SEEPAGE PITS 1 Depth _/��__ _Sararj 1� �- _ Number
<br /> i SUMPS L I Dntancet naaeresl: a Wag �. ' '- Foundation P"VotiV Line-Ie4- i
<br /> DISPOSAL PONDS C3 rtt,tc4Y ,�,u�i-� - �«- f j -
<br /> (thereby Cathay that I brie prepared this appircal+on and that the work will ba dnnu in occot(mnce wtih San Jois"i,l county ordinances,slate Laws, and
<br /> rales Sitio reguiations of the San JoaQuin County
<br /> Home owner,v kenaad agent's signature certifies the foNow+ng:"I cersdy that,n the pd,lormbnce of the work for xtuch this parrntl is Issued.I+hall not
<br /> 'I employ any.`s-son'f1 such manner as to beefFnB irtbleC4 to w'otS.msn's[Ompensal•on favus of California,"Censraetelr•s bhang or suL}Cenlra[hng tVgnatVtC
<br /> Cenifki tf13 Ioq 'ng:"I certify that in IM pe£forrtlanCe of the wort for which Ilya pa:mil is issued,1 atoll employ petaon&sutl^l to workmen's COlylpanaa-
<br /> tion Laws of Gafllorr.a." .
<br /> The applicant mast cae for ail reruirod inspections, CDrtpleta diavnng on ro,wte s•de. f
<br /> Signed X-
<br /> � Title- f1�x7z _�---- /- -LG-9._3
<br /> r �.. Date: ,.._....
<br /> I FOR DEPARTMENT USE ON1Y _ '
<br /> Appkisfion Accepted by e � {-
<br /> r,
<br /> t �� r _ Date J�>- l ?.ea 2" �
<br /> h Out inspectron by o Oats AF' Finaf In¢Pettinn ny_- �'r Li-i�"-_ Dais_24z,71-9-
<br /> ice. ,s_.
<br /> . C� iogal omnysner. _
<br /> Ap(•llrant - Return all coplon to: San jaq,lsa County pnbllc Rrtalth Scrvlc+q
<br /> 11 Fri rnnn�n tel HenJth pPrmlt/Sorvlc-. 'a
<br /> 1 445 N San .f o aquln,.I' 1) Rha 2POgi, :t k.n, CA I+S^OI
<br /> FIIi FEF AAtpVt+7 CetE AMOVk!ri Ftr'T"s[D -�-
<br /> I1][ I.VI�FC C'S.s RTcovio By DATE efRM1! NO,
<br /> v r.r le20
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