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__ _ �: � --�r� _ ��,�� _ _ _ _ m � :�;�-mow :� �^'•.�. s <br /> �ppI,ICATI a:� Foil P!'"IT <br /> SAN JpA-NV RCOUNTY OSIENTAI LLALTIi DIY SIOIC —ALTH HVICE��fi'=Iv 111 <br /> CA 9520)1 L3 <br /> P O BOX 2009 <br /> 091 S�KTON 9 <br /> APR 9 1991 <br /> izcate) <br /> (Complete is T:i� crsbed. '""•:s <br /> t to construct and/or 'netaltlq T/ �aa of 5aa <br /> 1911catscn :a neretry �e to San Joaquin County ror a perces 4 and 1862 and tbll j f�a�a� S <br /> a�1►catica :s mere in campllance with San Joaquin County Ordinance No. 9 mel( <br /> ,;paqu►a County Public :{talth 9rrricea. l,ot giselAeresga i <br /> . . c.tYIr <br /> o AaOns+ j7�Fes+^ Phone <br /> "Fa f���e Nor Gv/a, Address -- <br /> - ( a Nam �*^i Na <br /> '-'censeffa. S ��' Phone <br /> Address DESTRUCTION ❑out pr 9erysce 4-11 L <br /> LanUactor WELL REPLACEMENT G OTHER <br /> Kppf,toring Well <br /> NEW WELL <br /> TYPE OF WELLJ.PUMp' SYSTEM REPAIR ❑ PpDp, LINE <br /> PUtAP INSTALLATION ❑ DISPOSAL FLO. <br /> SEWER LINES �r� OTHER WELL — PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK c 'AGRICULTURE WELL __� - <br /> FOUNDATION <br /> TYPE OF W� ARDBL�EM AAEA CONSTRUCTION SPECIFICATIONS <br /> GATIDNS Dy o1 Wow Casing �-�--� <br /> _INTENDED�S� ,]Man[ac- Dia.of WeIY Excavarwn..-�-� <br /> ❑open Bonorn sL„4o PJ[— Saecdicatrona Ce-.��^ f <br /> .i Mdultnsi Type of Caun9 19 4, )S Type of Grewt�!^ <br /> $1 Grit-1 Peck 0 Tracy <br /> Dpmsuiu Ptsvae Q Daae Depth Of Grout Seal �- <br /> P ibl� Sl DtMf <br /> Surfice Serf Insteeed by <br /> 7 hrrpatan 12 +�N^��" �ApWoa. Depth Eastern H.P. State Wort Dorm <br /> �� <br /> ReoaM Work Dans U Type of Pump 94a1.1stg Matarsei 5 1kPth f� <br /> Vag Dostruellon ❑ well oiamesaf rillar Maude►, 6 DePth <br /> Depth <br /> avtrlebte vnthin I06 feat.t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f3 REPAIRlAPDITiON LZ septic system <br /> DESTRUCTION G Isystem perrr+teud it publu latter <br /> .ttpation well serve: Residence <br /> Commercial— Other <br /> bet of linin®unite: Number of bedroom$ Water table depth <br /> ,ts <br /> Charactas of wit to s depth of feat: Na.Cpntpenmenea <br /> E3Typewfp Cafsacm»! Method of Disposal <br /> ,EPTIC TANK <br /> rKCi.TREATMENT PLT.C7 property Line <br /> ! Foundation�----� <br /> Dilunu to nurnt: Wap � <br /> Total lertgthhsita <br /> Cl No.8 Length of tin-1 Property Lina <br /> EAGHINU LINELINE ��- <br /> Cl Distanceca to nasrest: WeH Foundation <br /> =1LTER BED <br /> Number <br /> f 1 Depth - � Sire f Property Line- - <br /> sEEPAGE PITS WIN Foundatwn <br /> sumps t,i Dituttce w neenat: <br /> sno <br /> DISPOSAL PONDS ❑ <br /> .state <br /> I hereby cenity Inst f have oreparea[his aaplicatwn and snot tna vola m6 he don@ In n[na p-rfo r�nu oath-worst(ofh San 'n county which this oarmit n,ssued. ll not <br /> V46 and regulations of the Stn Jwauin Count? I certify t or tuo-conitarting sipntture <br /> Home owhtr or hcansad agant's signature cenifies the laryow�ng:" aman's contpensa• <br /> employ <br /> s the parson in:"I unity trial in the pertarrrunu at the <br /> for which thil permn is isaued.I Shell employ persons luopet to wo+ <br /> implOY entl person in allGO riYnMr■3 t0 betama■uo16t1 to WarMmert's Cpmpensavian lave of Celifpmia."Contractor'* Irin <br /> tion laws at Cslifornis." <br /> The 0001 at al1 tot aM required ins Com <br /> c a daw drawmq on rete - - -rte Data: <br /> Title: u <br /> Signed <br /> �� ��FI pEPARTMEN'I USE ONLY ��JArea <br /> ,applieatran Aeesated by pate.. <br /> Date--Final Inspection by <br /> .__......_ ..__...-- ---._............._......Pft t#-Clout Inspgcttan by .........._.. _..--------__-- <br /> Additional Camm-nts: <br /> 'Scoot - R jokQUIN COUNT <br /> -tura ail capsae tut ENVIRONMENTAL hEALTIt DIVISION PERMIT/SERVICES <br /> 143 N SAN JOA4BIS, ? O Box 2946. STt701Ci41f, CA 93201 <br /> K i ElVEO 3Y DATE PERMtT N0. <br /> s FEE AMOUNT DUE AMOVtiT REMITTED HE <br /> � ice„. <br /> HFO f �1/f T <br /> E }3a raEv.i�•�ii tqt� 1� 11 ✓ ... <br />