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I"f5�)APPLICATION '/�•J /��� �C,Ci �� <br /> a SAN JOAQUIN COUNTY PUBLIC HEALTH SEsIVICES Ft1� 436f 1 <br /> ENVIRONMENTAL f1EALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209>468-3420 l}'}ly IF-!r-�J <br /> P O BOX 2039, STOC%TON, CA 95201ass - <br /> PERMIT EBPIHES 1 YEAH FROM DATj$ ISSUED <br /> (Complete 1n Trlpllcav>) <br /> Application Is Ivrea Sado to tart Joaquin County for a perait to c n.truat an.t/rr :nstatl the verk t•retn de.crtEeJ. .h1. <br /> appllcatice E• safe to Copllance VIth San JoaOulu County Crd:nsncv Ke. 5c9 avi Ibo2 ata the Rule. aeht R.Rn1a11Cno of Sen <br /> •� Jwyuln County�Pubile Health Services. ,t /J <br /> Job Addteu _6w 'Q z [� _�___. C." /.ap/-...—_. Lot >tr./Ar,rewRe ?2i <br /> ��,,����/a������ .____._^..�.�_. <br /> O.rrw's Nerve 5e4114 � ',,•,Ar�' .jj�am� C`` //�//��fSLn tlffjjlL��2�y_!S_.Y= <br /> Denha(Ipr �l LJJI -�o,K4&Z:tadtete L v__,,Zc v .. _ C!_`eEel`nte No. �PnpneG%7 <br /> TYPE OF WELL,PUMP ..EW WELL�( WELL REPL EMFNT i. DESTRUCTION 'l Opt of Service well ❑ <br /> PUMP INSTAI..:y1ON 0 SYSTEM REPAIR 1 OTHER X�17. ROnitorlAg Veli ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ___ DISPOSAL FLD✓��_1OP. LINE <br /> FOUNDATION _ AGRICULTURE NELL == OTHER WELL � PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTRIN SPECIFICATIONS <br /> IndweoW�, ❑Open Bonom Il Mercer. Ob of Well Eacovalion _zV"z_ Ow.of Well Gang <br /> I!DortratK:/Narip. pt�Gravw P.ck }i eft TYM of Camp N <br /> /g� SpaKalana <br /> 1'1 PlAlic�((CE /���II�ttOM <br /> O�RIt �I L . Depth of G• PI Sea Qy/ Topa of Grou /h <br /> I I In10.• �eCflApl.d..Depth I I Enter. Su4ac.Seri m.1a14d by <br /> Reps,Werk Dore Type of Pump ILP. Stan Well, ChM_ <br /> WN 0""Ctq ❑ WN Daniela, bea:ist Na Leda. a Depth <br /> Depth_____ Tiller Material E Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I 1 REPAIR:AOOITION I i DESTRUCTION.1 IN.anpbc arn•m pa,nvued H ptoh(aawe•u <br /> auaNbl.wdhn 200 In61 <br /> IMIaR.tiOn vdl MM: R•a440ce_ CO. 'cw_— Dllwr <br /> Nunlbw of 4vu•p undo:_ Numbs of bedrooms �a\ <br /> Chbectw of Foil to a depth of 3 Mo: __W.tw ubb Oeolh .✓` <br /> SEPTIC TANK ❑ Type/MfD C.p.CRy No.Compalmenta _ <br /> PKG.TREATMENT PLT.❑ M.thod of D4posa1 <br /> Diebecit to nitron: Well Fuurod.tan Pro;eny line <br /> LEACHING LINE ❑ No.\Lmpth Of 4v. __ Tma1 bnpthhue <br /> FILTER BED O Oiatnw to.'aw: Well Foanoa:an P•open,lin• <br /> I <br /> SEEPAGE PITS I I Depth Sire <br /> e' SUMPS LI Distance to rosiest: WH FNM.Inn Property Li" <br /> t, <br /> DISPOSAL PONDS ❑ <br /> ase 1 hisb,cartel,IMI I leve prepared the eppticat4n and that he work YnIJ W Con.in.ccom.nca with San Joao,.county oId,ra.c..Hate Is..and <br /> r.*.WA repute w.of IN S.n Jopum Cwnty <br /> Horth owyer w Lc.. agent's aiBNlwe can041 IM telbwnD:'"I carol,1 W m IM pa4ormeoc.of:he work for whkn INF Lwmt 4 co.".I UMR not <br /> woolly any pwaon ii each nos,~ac to be(omu wbect to workman"a compensation 4wa of Cakl prka"Conbanoi s heap or wLLcontractinp apnaturs <br /> WtIEM The foEOwPtp:"1 C.Mf y that in IN Pa4wuYncl OI IM work for~Ills gtm16 issued.I kNll employ pwwn.Fubiect t0 wIXYmwl'.cove,sonse <br /> ` tion lova Of C.IHorNe.'• <br /> I* <br /> The H W repo nipctiona C�o/m�p•u dnvmp • Hwa �— <br /> +� SipnW YG— Title: ra -%� kY6'YLlILiDwe: T <br /> t PON DEPARTMENT USE ONLY <br /> w, App:itation Accepted by —40 —1 y/ _ _ Data �j A,. ^^ D <br /> A: PH a Grout Inspection Hy `/ ' �f _' a•e_ Fina1 6upactwn by Dale <br /> L AQdilgntl Cwnmenu: <br /> fi ApP.le.nt - Secure .11 <uplee to: San JoaRulo County Public Health P ,•a <br /> 'r B.vlre.wentel Health Permit/Ser Icae•r <br /> NS H San Jc.,Wn, P O So. 3000, ::xn, CA 95201 <br /> Wf0 /UADUNT DUE AMOUNT REMIYTfO K RECEIVED BY `A <br /> — {E PERMIT NM <br /> sea J9 <br /> .E.tans IfIlh"..• �— <br /> M tai _ <br /> y -nitytr.ew....�.w. .. . .. � tom•✓�� • <br /> L <br /> L <br />