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APPLICATION SR <br /> µ <br /> SAN JOAQUIN COUNTY PUBLIC HEAI, 1 SRIACf:>~--S—CC! ''Zh <br /> ENV I HONEIENTAL HEALTH D T V I ��� µµ <br /> 445 N SAN JOAQUT"t, PHONE (209 aR�.tFi2G d-ID q, <br /> P O BOE 20U9, STOC%TON, CA I�Gz(�Iu <br /> . rrj }fes <br /> (Complete 1n Tripllcat / <br /> Applleaalp 1s prey ee!a so Sea Joeyulo County ror a pereit to construct and/or :•stall the wort heroin aerrlhca. This <br /> &WILrAttee to seals 1.. eopllu,oe .Ith Seo Jn.Ru1n County Oraln.nce No. 5.9 and! 18c2 tae the Rol•G .>b RcKulaticn. of San <br /> Jeeelas Catty futile tl.alth e.rr�r <br /> JooAedaM g W t u — -- 1��a— Lct s,ae/ArreeAe <br /> Fm n KA Fm re-7 r(1 V�(ne �A�, z . N <br /> Ovww'a Neva, �1./`•/ • 4..SC__— .�_IS-. <br /> Gon7etlIX m AAr-✓Vt1I']/•� �_�_M�t ��a�_Y Y t I_�.�(L•-_Lac rnft Nn.1(�}'�y�,y_PnorY l 1/� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i• DESTRUCTION I�Out or Service V.13 <br /> PUMP INSTALLATION C SYSTEM REPAIR :1 OTHER C Ro.i tome Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ___ DISPOSAc FLD— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL __ OTHER WELL__ PITSISUMPS <br /> _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑fnikothal ❑Open S.Rom ❑M. w Oa of Web Esc.v.lan Cu.of WW C..Ino <br /> :7 DIXnaex/P Nau ❑Geysl P.cl, G Psi, Typo of C.unp__ Sp. ons <br /> ulcat <br /> 1 PoNk 1.1 Olhw r Tighe Depth of Gwul S..1 _ Type of Groul <br /> I I Nrgaael _Appro..Opti�)y (�1t�Eulwn �'�ud."Sul Inu.I:p oy <br /> Ryer Won Done U Type of Purrrp�3LL1 N.P. [� sus Won Dong <br /> WM O"Isuedun 0 . Wa DWMter See3+RE Material s Jryt), ISI, M <br /> ;1 Depth._ P113er WILertal A To, <br /> 1 TYPE OF SEPTIC WORK: -NEW INSTALLA110N I 1 REPAIR/ADDITION I I DESTRUCTION 1 1 INo PIT,I.....am pamuwl A putwc <br /> IretYY(NniwE a":: Residence_ CoOtherce, Other <br /> NYof wing#M— NumAer of eadhI ons, <br /> .,CMreeler of MA to a depth of 3 feed; Weer telAa depth 1 ` <br /> SEPTIC TANK ',. 1 O Typo/MIS Cap.cru_ - No.Conn.rtnrnta <br /> PM TREATMENT PLT,❑ M.Iho l of Disposal <br /> ' Depen u neahod. Wee, Foundelon Propiny Law i t` <br /> LIULF"NG LINE ❑ No.A LwVM of Vnas Tow Nnpm/.u. <br /> FILTEJI SED ❑ D"ivunp u wNxL Wed 'Fwrwaton P.opnty I. <br /> f l � <br /> .S�EEePa�AGE PITS 11 Depth Sue Numw <br /> eN <br /> '3u 1-' LI DRWrce to reMeM: Wb F. hexwh___ P opens,LSM <br /> DISPOSAL PONDS ❑ <br /> •1 mob,LnMY"I l Nee pnnehed sive app'c.unn ane th.l the.pr.was M dope in.ccadence with San Joeeux,county awMncee,use Lead.And <br /> 'nAK saw fNllkpn W IN San Jo span co ety <br /> 104-seas,Y ImasneeA"ant's*W&IYe Cess the IQAPN q:-I C"ty INI In the pertam.ncs of The won Tau which the Wend of euusat 1"rot <br /> Mlnlpf 4m,pereffrf In orh nMMlas aF To beo nM w&,P:t It,evorETan t rornpanNlson Nw.of CAlwhu,."Conl(KIO!s heing de WDCOntreClalp barend e <br /> pRtllae 0010eo.mlp:•T prorY tNt h"WIRMIN ca of IN eorL Id wfuth Ihis permt Is Y.uAd.I SAAB s r,,I"poison.xubp t 1.wortmui a compenY- <br /> ,pon'Mne of CaMoNWa." <br /> :The,aFOB�unlr{m�t/MI Call he YI sapped ar p CatWeu dewvp w nv.rr•d.. �� I�2 <br /> oil*: .LL1 <br /> FOR DEPARTMENT USE ONtY I <br /> Apo"flon Accepted by rty..c 1/ 'tAa.t� Data Arw <br /> i►N M Grown M OKOM W f F"IrupectNn Dy Ow 9—'T <br /> ACeAIaW Cunweete: <br /> Appltcset - Ntur. .11 coplea ;o: San J....1. Couoly Public Heath Service. <br /> Env l roanen l el H.Alth Perelt/B."Ic.. <br /> ..5 N San Joa9u I.. P O Sox 2WO, SIEn, CA 95301 <br /> TI4 POL FEE (AMOUNT WE A'M+OONTAWTIO CA „ AEECCINID E'r OAT( Pf KAYI r.0. <br /> ./Jw taUafVuw.rr... 1 Y' .Q0 �Y <br /> a a" 7 <br />