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APPLICATION FOR PERMIT <br /> SAN ZOAQUIN COUNT? PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN ,-OAQUIN. PHONE (209)468-3420 <br /> P O BOZ 2009, STOCXTON, CA 95201 <br /> 2&MT EUIRfiS 1 YgAk PROP DETfi I <br /> (Complete in Triplicate) <br /> wrl herein described. <br /> Ap�l.itastlos is sersey re to uA ioaaule cousty for a peralt to ccnatrue� and/or insult ttu ReNLtloa• of San <br /> ewllostltss is erAe is cads&*-* •t%A fes o"-14 C ty Ordinaaee Eo. 549 and 1862 and the Rule• and <br /> Jee4sls Catety halle tsslth Services. r <br /> 2-2- '7 C'rr="J----- l'°t stte;Acrcts. 0 <br /> Owerr'e Nsnr AON•et — - - <br /> /?���� L.cense No.�Pnone t - <br /> cenow Mote Is F <br /> WELL R(PtACEMfNT DESTRUCTION Ll out of Service w12 <br /> SPE OF WELL/PUsf► NEW WELL OTHER 0 Itonitortng Well CJ <br /> PWP 04STALLATOON C SYSTEM REPAIR <br /> MW SEWS LINE DISPOSAL FLO. PROP. LINE <br /> D'TiTANCE TO NEAREST. SE►TIC TANK PITS/SUMPS <br /> FOUNDATION AGMtC URE WELL OTHER WELL_. <br /> INTT:NOEC r.es �,� WELL MOWA CCNSTRUCTION SPECIW7ATIONS <br /> G D.a o/WN Eau a+ore_ Dy of Wa Ctwre9 <br /> 0 fnOwtrai O Down 64"01" Spwt ealaxea <br /> I Domewrt:lf4reeee Q Grs.a Ped racy Two of Cary------ <br /> I I PUNK n otn« <br /> Dews Oeotn of ro"Sea l rpe of Groul <br /> i 1 In.O/Ile/t —Aypro•. t 1 Isawn Swtsee Seat Mslaeed M <br /> P Sud Hort Do-*- <br /> i spec VMNrt Dorn J Ttrpe d PumpSog Materiel A Depth (� <br /> Wei OMrucMa+ O +NSE Orrt»ter \1 <br /> Taller Mat.ariel • Depot ,f`J <br /> TYPE OF SEPTIC t1VD11K. NEW H'tST-AL/CATION REPAIRIA00I 1011 i DESTRUCTION ko,aAawswlI�.n 2mS.'G�Mt+��J q�twc�'� (� <br /> wasoftron tai or": Roodence-V CortirwC3sI 0 — <br /> to~of * <br /> tletry twt�f u neer of Oeoroorrr <br /> • � Wsr«able depth <br /> Cltfraeut of W M•do*of 7 Int: � No.[ptep«tmMeu <br /> w i1C TANK O Tyowli fsS � Capecrty <br /> r ',` Er/eit", 1 h w 1 n <br /> MCG.TIIEATSIE/tT KT.O J Q A� Property L <br /> Oitw+a to rte«eet. tAgf � °w+6ew°n <br /> ', Toro to/sue <br /> LEACINNG L"* CI NO.E Ls+PM+d Ytes (L f/./ Vropeny Lues <br /> FILTER•ED O Dietetics to macer. Wee t ipnMldal.W1 <br /> SEEPAGE►ITS I I Depot Sae N.wnLa <br /> sum" LI DafrKs to Wee jawweton_ hoGe+tY Low <br /> DISPOSAL PONDS O r <br /> I hsef0y Oeltify aW I hWA Drpyrsd M.e eppbc~"that Mn wal w+e W done m see dsrxe w.rn San Jtssgwn county adnaness,w .end <br /> nd"WA popftslons of*4:an Joeouw cowVthat n Mee pen ymsnee of the .Wk for whack tnw p«rnl is oetfed.I eneE not <br /> ttiorlte ttwrtef <br /> o'%M 6111001111's e1Dn«`�condom Mee. to+on�np . t eroh <br /> ox foy«rF[Swoon M ordt wt«trtsr M to OecorM wtbpct to woranesn'e Poch th4 toonper terve of Cd.fwnu"CwAoy Per& sub or wDcoil~' c rWeenw <br /> @Wass tale fofeee�IS:-1 OWWV*won M.e ponorwt«eee Of M+e wort lo,wert:n ins C«^M•rtnMd.t mail tM+VIOY p«ea+e wppet to worlm«e'e eorrep«oe- <br /> o w beef of CEfforwIs.- <br /> The wite.K c+ ne ;,ew+a«•d «,rw«..Lace. _ 1 l — f 3 <br /> Tale <br /> 6-�- 1�-t t/1 0. <br /> swarf <br /> o FOR DIP"TU91417 USE ONLY <br /> Date 1 _ _ Area <br /> Accepted by p DOW <br /> j. t Dote �-f(' 1 I"IMMIM ton by <br /> PotGrwt wtopecoon <br /> A4011I0IeM Contiwtw: <br />_ A►Pl1c&At - flstsfs ell t:op1N to: 3tlfosseelal health Wrwl Itts31 trY lca• lees <br /> 446 w gas JoWYla 2009. atla. CA 05201 <br /> FEE Dlei T wlWt-il0 I <br /> MD By 0 t KItMtT�. <br /> .en <br /> on t.a <br />