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<br /> APPLICATION
<br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br /> ENVIRONKENTAL HEALTH DIVISION
<br /> 445 N SAN JOAQUIN, PHONE (209)468-3420
<br /> P O BOX 2009, STOCATON, CA 95201
<br /> PERMIT FYVIRF.S 1 _YEAR FRUY DATE ISSUED
<br /> (Complete in Triplicate)
<br /> APrll[a Llpr 12 hereby arae to Pan Joaquin County Cur . px,It to crnetrurt and/or Install the vork herein described. This,
<br /> opplleatic. 1. tWe ib eaplianee vtth g.. Joaquin County Mo. 51,9 aM 1862 am the Rule. and ReTt]atie.. of Sen
<br /> Josquln Grimy Public HealthSer,Ice.. _
<br /> Joh Adlr. ,
<br /> .W r��(� V11Z A+/ /2 __--_ C.n , j-4r?j._ Lot Sive/Acreage �.!/ —
<br /> 0...N �- /1- ( /h NY— Add,It�[/2,, -/ _L�y Jl� q)-lr�E
<br /> N. pph rH-
<br /> Cpnacl.r���+ _Admtss�_T/�t_S.LiI�AL�L�ct�NOg�yPhbne
<br /> TYPE OF WELL/PUMP NEW WELL O WELL REPLACEMr NT I DESTRUCTION Ll Out of 9errlee Hell ❑
<br /> j; PUMP INSTALLATION ^u SYSTEM REPAIR OTHER ❑ Monitoring Well ❑
<br /> r
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.LINE
<br /> FOUNDATION __- AGRICULTURE WELL _ OTHER WELL ?ITS/SUMPS _
<br /> 1
<br /> INTENDED USE TYPE OF WELL PROBLEM A3EA CONST nuCT10N SPECIFICATIONS
<br /> ❑IndustrMl ❑Open son" ❑Manraco Dna of We#[-aratwn- O:a.of WW Caging
<br /> r
<br /> tit CI DomeatclPw.0 ❑Gnre:Pock [] L¢r Trp of GNrp______ Sp•<dkotms -- ,.
<br /> I'Ipap 1 M
<br /> -.1 OIr it Own. Depth of Grt Sam TYp of Grout_
<br /> �'• i 1 hnporw0 Approe.Depth I 1 Easwrn Sudacs Snd In...tax!by
<br /> Y1 Repir Wpl Dore. U Trp of►ramp ILP. 9th Won Dore-
<br /> WON Orr Ncno, U WN Discrete, staling Ik,terlal A Lepth _C
<br /> Depp, till., Hitachi A Depth r
<br /> 1 YPE OF SEPTIC WORK: NEW INSTALLATION 1 REPUNUDDITu)N DESTnUC110t.I INt wpm qN:m pvm.ued d public sewer a
<br /> tmtAMetion rW Nn•: ReeipMu>(, CamwrcW_ Other
<br /> 1 Number of oxong uMo:4- aNnAgel of popcorn. ZZ
<br /> -
<br /> Character of Egged to•depth of y feet: J H• Fes- _._-Water took,depth
<br /> SEPTIC TANK&W&J-0 typo/Mfg Gpatr—__ No.Comprvnenn
<br /> PKG.TREATMENT PIT.O Method Y
<br /> o/Diy»s
<br /> Lvrvtco m punt: WIN- Fourde:ion Proponv Lip
<br /> LfACNINO LINE No.i Length of 1'vn. _��[���.���v� Toe.:k,rgthi n[e_„ r
<br /> FILTER$ED ❑ Diaiuco w rMu..0 WNieti�.z.. Founor.Pon/2� NopnY I" SA
<br /> SEEPAGE PITS I I Depth-,if-?4," S".t', .�-� thumper tf'-�✓ - '+�
<br /> Ef SUMPS D( Draw.ie..41141: Wait FourWuwn, PropM Line
<br /> y
<br /> DISPOSAL PONDS ❑
<br /> I herebr cMdy 1141 I nate p IM.appca
<br /> blwthatJu soh
<br /> n and il m4 M nt dow a<corwnu wnh San Jopuitaxing, nctue.
<br /> conlY ordna •.sInks,arW
<br /> ruin arta npadauoru of to Sen on JoJo puin I;ouo[y '
<br /> -i', NMM OwtMl p icax.d pent t.prumra undw iM logon. .9:","nifY But In the pador,nsnce of the wwk for a wh this prmu 4 mood.I shot no,
<br /> t elttPIOY MIT praort N arch m.npr a to bseprw wbNwt to muYnun s compon.alion W.of Calilorns:'Contractors hung or wo-conuocting wgrteture
<br /> 7• prYftM tb lotowinp:"1 Con ty,the,in the p torn ice.or JM work for Much this print i.ueued.I uuu amoUY portion,eubRKI to u o,kmM,,,cornpenea
<br /> Hon iawa of EJNdme."
<br /> The eeH for a, tipu r+�RIt dowep on etch.ado.
<br /> /
<br /> 51WNd c' ' Lv(�(f TiTido: Do:.:
<br /> .R DEPARTMENT USE ONLY t1 q L�
<br /> A�t/tJp�5tw lar _--111_i\_,►]�n„tA,(A�np,,.tyJAA.1SA�qq `.r-���) Z. D.i. JCC-•��-�n- 1/�y/ A,w f1�zro11 -Gr-0
<br /> p Ordu1 Rcpettlon or FJE��µ�rTreti Fin.I In.p.euon pr- ` 'r+"
<br /> AddNbnel Corttrtwtts:
<br /> Applicant - H•tur. .1. copies to: Sao Joaquin Counts Public Health Sertices _t,w
<br /> 6nrlruaaa:[al Health Pdralt/Services \
<br /> y ••S N S.. J..qule. P O Dox 2009, Slkn. CA 06201
<br /> f M,% ?MOUNT WE AMOUNT MEM�TT10 CASH FECEIV[D DY DATE rfRM1i N0.
<br /> .tN 1IN Llr."..I �
<br /> l�-��' .7 O
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