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sow <br /> APPLICATI0N FUtt I'E iIWT <br /> SAN „OAQUIN COUNTY PUBLIC 11LALVII SFK"CES <br /> f:NVI[tVNMF_N1b7(J11EALT CA <br /> nI95201 <br /> P 0 BOX 2009, <br /> (209) 468-:3447 <br /> (Complete In Ti-.Plic'"p) <br /> osa Count,, !.or a Ierc:t to centtruct end/or 'nat*,i the vorlt heron dl.atiobsdof Sao$ <br /> r.pyllcation is hrrcby Made to :Ian JDa1 <br /> L or.-* :862 and the Rules and ifals,1 <br /> apyli:atio0 Ie enter In Cony'•llance with Sar. Joa9uin County Ordinauct NO- <br /> to <br /> 9 <br /> 3<rrttR.. <br /> Joaquin County public Healt: 77 Aj Lot SEse/Acrvoge „4Cr..r• <br /> Joh Addrrsc ZLI <br /> Add­sc <br /> Gwner'a Name T�L.�n���•--�1�- Srri.a- '� <br /> ' ,.s' AJ:•cit ! ����]ur:�jG"Jr-=1 'J�i��_L'[r^5c r. well Ll <br /> Coniratlw 1"'=tf111'l,J1l` ___ DESTI+uC71GN Ll a t �f F Y <br /> Wtll REPLACEHf"r: •-� Jrll [T <br /> PAIR <br /> R <br /> TYPE GF yNELLlPL%!.tP. In• SYSTEM RE � <br /> -- _ pL:hIP I!JSTALLA'f N DISPOSAL FLO.. PROP Lir+ <br /> . - <br /> SEPTIC NK _� SEWER LINES _�--.__—_ PITSrS' - <br /> DISTANCE E�TO NEAREST TAN r AGRICULTURE+VEILOTHER WELL_��,^ - <br /> FOUNDA�!4' r SPFCIfICA-71pNS f,' <br /> i.ItLEK.I AREA r;ONSTRUCTION _ CIf <br /> INTENDED USr TVPE C' r --_--' 0.a of Well CAII04 -- <br /> 'ranlee:a 0'a of Y+Rfi EaCeYlI.0' <br /> P'I(�[�1LIal IJ Upen IYrr'}Cr rP. cl.�- —_-- U ' <br /> icy Tyr*of Grdut <br /> .uayst�clPr'vr2r C1 011Gra�q ._ <br /> Deas Oeulh of Gr0ul Seal - `�1 =fk = J <br /> !"1 Other - <br /> ia Puplit g;,•f sea Seal Incl Ule3[4-�_--- <br /> tJ AolKor• 06^1111 rr.� Eaatom .. ----- -----' Slate Work Dont <br /> Pump H N — C• J` <br /> R604"Work L' iyl o: Baal Lng 1G terSal � north <br /> Wait Castruct,nr. :1�Wafl DIC Nattrial L rxrtf'. . _-_...T.---�-^�^� <br /> lf d lrhb[srrvar n <br /> Deolh _ p <br /> rEPA,p,AQG <br /> iVE OW - NC_WI NS TPLATG <br /> ave sable w':h,n 200 IReI.[ <br /> Instillla:,on will Nrre: Res,dtnce—_ Commvr al -- Other <br /> !lumber at living wal►t Number of bsdl0omr�..—� - -�. —„W&W labia dePtn r� <br /> Llharacvr o!wit to a depth of J fast: —^ _ Cspec-t r_ - No.Companmsnu 1 <br /> SEPTIC TANK ❑ I,Ps/Ill - Method of DiwOtAl <br /> P0.TREATMENT PLT.C Fc,ndat-o l�— -v PropenY L`na <br /> Dillanco 10 na9rlrit: <br /> T <br /> alai tergthlmra — <br /> LfAC"IN G LINE Cl� fio,b Lenglr.of Imeo- — Praper.Y Lsn• <br /> FILTER BED — <br /> L,tRp_�- r-oundrllon } <br /> CI Distance to 1'1447091: !�J <br /> Number <br /> I 1 DaV1h Site--.�--- Line <br /> SEEPA GE PITS foundation_ propertySUMPS L1 Di$tancR to Pearaat: Well � <br /> DISPOSAL PONTIS <br /> t Mleby ctrtifY that t have Pre Pira 7 lbp,74�C�liOr.erlii Ih]i ShR wart .veil be dor C�rt DCC OrtldnLe w�[h man JJaQUIn t0un1}Ur6,M1�!1Ca4,7tR[a laws.and <br /> ruiaf and rejulil+0na of[he San Joaawn County I "i C qn,,l that In'he Wrr Hance 0f rhe w�rtr 104 whh,h this permit.a Issued,I$hall not <br /> HOlna owner 0r licant*d aQen1'a isipnawle Cenihoa the to tOw nQ YComlra0na fubNct 10 wort man's ConlpRnaa- <br /> am0I0Y anY pela0n 0 such mannar as 10 pet manubrect 1g1he wort3 s co oor, pe n+ertt'e isi�d,'�gr,all employ ape i!hrr+ng c fish cOntrOcbnq arQnatu+e <br /> tnn.1,R$the fnRoY,ng:"I r fY tMt in:na toe <br /> IlOA taws of Calif <br /> ' r r I. unI ins{+eCt+�ri. `""Mete drawing on faverae sloe. <br /> Data: <br /> �' <br /> The aypl� rrx•tt rrsf1L^i= -�----- <br /> Signed <br /> of.PARTMENY UfrE ONLY �y <br /> -1-3 — <br /> Lt' / Data <br /> Applicat•,n Accsatad by Data <br /> Date <br /> � final tn$pection by <br /> Pit or Grout Inspection byl2 •/r oJ1)�. 4/1. 4c.cf' •" <br /> Addltlond Conn"nts:��' t <br /> llyflllcs,at _ Return 111 copses to' SAN JCAgUIN COUNTY PUBLIC HIiALTH SVRVICEit <br /> ENYERCrN1rE_NTAL ,IFALTI; L'[YIZ1104 PERX 1'T/9NIIY ICES <br /> 445 N SAN JOAQUFN, P 0 I70% 1009, 871)CKTON, CA 05201 <br /> K AECEIV EO FSY GATE PERMIT NO <br /> FEE APADVINT DUE �MfIUNT q£IA x17£0 r_a_-_i r� — y. <br /> Ik�C � f 0 �J. lSrrt rI7' �f 41-1QSZ <br /> r IN li-7•'ar ,rw6i ~' <br />