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SAN JOAQUIH COUNTY PUBLIC LEALT$ 38RVIC$S .r; .
<br /> ENVIRONUMTAL HEALTH DIVISION r
<br /> 445 N SAN JOAQUIN, PHONE (209)468-3420
<br /> P O BOX 2009, 9TOCXTON, CA 95201KXPTRPq rgom DATE TUM
<br /> (Complete in Triplicate) =j f
<br /> AppllcatlOR 14 hereby Inde to San Joaquin County for a permit to construct and/or instill the work herein described." This •�
<br /> appllestion 16 aide 1n 04+pllanee vilh ban Joaquin County Ordinance Ila: 549 and 1662 arm the Mules and Ilepelatlona of ban k
<br /> Joaquin County ftwe Health less.
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<br /> Jab Address . `7 CitWS.tL Et. SIZe/Aereag W6401
<br /> Owner'E Ner"A 111 -V/ I LEW A& Address .. _Pf10M Trek: �•
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<br /> rs�5
<br /> Canlrega Address /Nt.4t���Plt.r____-_ OcenseN . Phone"
<br /> TYPE OF YJELUPUMP: NEW WELL ❑ WELL REPLACEMENT ClDESTRUCTION C Out of Service ell
<br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D: MenitOrlig Yell,,C7 1 y
<br /> DISTANCE TO N1',hJ8r.-*Rll NK SEWER LINES DISPOSAL FLO. ['AOP LINE
<br /> FOUNDATION LTUAE WELL OTHER WELL
<br /> INTENDED USE TYPE OF WELL PROBLEMAREA' CONSTNS 34-4
<br /> C7 tndustnM .. .. C1 Open fSottom ❑Mantecs Di Meevation Die.of WsN Casinp
<br /> Cl Domeetk/Privats ❑Gravel Peek. ❑T Type o1 Casing_ SPe ns z r "
<br /> l•I PuWie fl OtTet Oahe' Depth of Grout Sea! Tvpri of flreut
<br /> t')helption;,... s.Depth I I EaFtwn Surface Sawa Installed by e e
<br /> RspHr Work Typo of Pump H.P. State work Done
<br /> ❑- WOE Diameter 8aalinS lfaterlal i Depth.
<br /> : Depth Pl11cr Material&'Depth
<br /> 7777
<br /> TYPE OF SEPTIC WORK; NEW INSTAILATIO REPAIR1A0DITI0N I I DESTRUCTION I I (No septic sparser tted k public sewer is
<br /> a pCe�m{ l..r t
<br /> jZ; ,x a available within BOO lest I x � ,r 1 rr� Y
<br /> k InalaNnien rmiS ser"...
<br /> erve RMWwtee_ CommwelM�Other
<br /> `r Ntlrrtbar Of ivitq unha Number of bedrooms � �+►�a� .' �� '� , ak r'� L rix
<br /> f h Character,of all to a depth of S fiat: Wear SabM depth a �•,r "r +1,
<br /> c sEFrle TANx' i7 7ypalMtg _ Cipeeky lVo".Centtportrtrrib»`
<br /> "Z-1 PKfi rREATfw1ENT PL7 O Methodaft
<br /> 4
<br /> 3 diarence to leanest Well /�.� Foundation Property
<br /> riJ
<br /> LEACHING LINE C7 No.4 Length of1ikmes Total langlhIsle ter .,. <,ts r e+tc✓ 0
<br /> FILTER BED O Dlttortce to rlserm W" Foundation Propwry Line + rt a *�'�+' � j
<br /> l 1+ '-:._: �•,r, is - r ' - - - - . 's. � ��t3 ,.. ry�
<br /> SEEPAfIE PITS I I Depth" Sia^ r
<br /> :< SLMRPs 7 �y.;_ Ll Distance a Merest.: Well Foundation Property
<br /> DISPOSAL PONDS q ,, / / "d her . 4''"T/1SIVK
<br /> r fL �I hereby cwtlly that I have prepared this application end that the work will be done an accordance with San Joaquin county wdKmartca arate Issas,end
<br /> - trdM,NM1 repWaibM of the SM Joaquln Cc mty
<br /> _faotM tswttsr m Wcenssd apettt'a signature oenifiee Me foMowrtg:"I arNty,that in the podairmonce of the work for which this pe, ki issued,f Mai not K
<br /> empl"any pwewm In eueh manner as to become subject to wtwkmen's compensation taws of California.' Convectors {
<br /> hfrMq or wb cantreetinp'Mpnakatr
<br /> tertiHso mire fobwirg h performance of the work for which this WrWt Is Issued,I shall employ pweons subject to worttmarl a sem%l4nW
<br /> '` } ►aver snare Of V-rk .:rvx -,; : .-. _ r , •ri ,:Sya1 ,t ver
<br /> The muse W far lona Complete draviing an /aide
<br /> Sales t s..�s t'�r.� /o~� �+• r� i�;. ,I
<br /> r. Thle
<br /> + Dia, y � kik
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<br /> FOR DEPARTMENT USE ONLY
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<br /> } AppEcitlnn Accopeed fay 'rte — - - Dole—
<br /> Final
<br /> ole /tree ro w , Mctt r
<br /> i.{,•.. - .-. airy, zva _ill- .,9t,�,.ri 4
<br /> Pk a Grout irrprMfon by Date FIMI Inspection by Date��•j�lf//��� '
<br /> ... x' u•r '.Til
<br /> AddkkmW Cmmena•
<br /> APPlicant - Return all copier to: Ban Joaquln County Public Health Servicer ' r• ; '� x yk r"
<br /> 3nV1r0rtieatal Health Perf1L/9ervlcea
<br /> 445.H•Had.;ion quln, -D no 5099. Stkn, CA 90201 lit '•' 1� r n �,t'" yr_
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<br /> Y GarvED eV
<br /> 9 �
<br /> 5
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