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APRL.L"i I UN <br /> SAI dOAQUIN CODA= PUBLIC EEALLTZ -*ERVICE$ <br /> Pj Eh'YIRMfMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> �%k P O BOX 2009, STO'=TONr CA 95201 <br /> �dIM FROM X?ATE LU= <br /> (Complete is Triplicate) <br /> AW11catidts to hereby trade to San Joaquin County for s pernit to eetwtruct and/or insta]1 the work berth described. This <br /> aypllcatiao ie s+de ix easpliwnee vltb Baa Joapuia County Orditeatree ho. 549 and 1862 snd the Rules and ltesu"tlons of San <br /> JOapnln County Public <br /> hmdth SerYiees. Q <br /> Job Addrom - T S L✓�ST to l:,+n/T f-l A/[ r�R D Cny 'T• } Lot Size/Acreate <br /> _ Owner's I�lams S•TF[.L/o- �C' IF AOdr.a �•Q• �BX z�r T1 � ! Phone <br /> ..'` /. &#44YAM, Die, #40 �e5�) 9l •3�2 �0 <br /> Contractor SRO n/ l! P / c v� Addle$$ r A me-'j-H, 64 Lrcen a No Phony <br /> TYPE OF WELL/PUMP NEW WELL O WELL REPLACEMENT Ci DESTRUCTION ❑ Out of 8err10w Yell <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Moeltor"w <br /> " D=STANCE TO NEAREST SEPTIC TANK ��_ SEWER LINES DISPOSAL FLO— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Inousireat D Open Bolton+ D Mame" Dra of Wap Esuvatwn "1 C' rs Dof W@* Casrfp Z <br /> ..» Cl Oomeaae/Pnvate )KGravef Pack ❑ Tracy Type of Cownp,,,�VC--S[NEA• scmaµn <br /> SpeCrlrcatepeq. ��• <br /> 1'I Publee n Other n Delta Depth of Grout Seal '` / Typoof Grow C ^rte <br /> y.�.. I 1 krtpateon _Approx Depth 1 1 Eastern Surlatte Earl Irestaprd by SB Ir-S Fx fT <br /> Repair Wort Done L7 Type o! Purtep -�— H P ^I Slats Work Dons nr <br /> Well Dnuwcuon ❑ Wen Dwneter Z-fr/Cll a6 ll.terial t DeytLGAG r?'� - [.,rr ,�► --> /'-$r <br /> -`� Depth "' 20 FELT Piller Msttrial i nent7n --3 r�h.•rn --� 3'-ZQ i -- <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I IND sopree system per" tied M ptdbk sewn is <br /> available vwthrn 2W lest.l <br /> Installation wM sore Resedenee_ Gonrnertisl^ Otfrer-� <br /> Numbs o1 b-v urns Number of beoroomt <br /> Character o1 NO to a depth of 3 foot Water table depth <br /> - SEPTIC TANK ❑ Type/Mfg Capacrtt' No GonWwwwrn•nts <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> Dwane to nearest Weil F*un"twn— Property Lino <br /> A�LEACHING LINE Ll No i Length of Irnea Total length/area <br /> FILTER BED ❑ Distance ID nearest Wet1 FDundatron <br /> Property Crus <br /> SEEPAGE PITS 1 1 Depth Sire Num' <br /> LL SUMPS LI DrstancA to newest Won Founaateon Property Lino <br /> DISPOSAL PONDS ❑ <br /> I hweby Cally that I he prepared this applocatron and Ilial the Work will to dons to acOwoance vwth San Joaoom county wdw+e"s stets Lwm, nail <br /> - " ft*m and regrlarrorr of the San.Ioagwn Count, <br /> Kowa 00001 or bowvw'd ep.ru a arpnatu►e Cwtdows the to+ewng -1 certety that In th+psAOrmanu of tiro work tw rrtrch Ctrs f»rrmt rt naued. I slid net <br /> employ any person on such manner as W become oubroM W wortoFMA a COmP*nutron taws Of CoMorn a-Contractors Iwtng Or sub-contraetreg aepnatwa <br /> condws the Iobwrtp "I grimy that on the perform w4a of the wort for+which this perrnn o r►sued 1 sham employ ponems wbfect to workman's COrnpsnaa- <br /> teen tows of c4wdcwrrr <br /> The apWrcant must cat for ail rsqure0 innpeciewo Cornprete drewng on reverse 040 <br /> Sigrid X- �� fT.I�� _ Tale flac IAT, Crroc��r.rT Date <br /> FOR DEPARTh4fNT USE ONLY j I� /17 Appletatwn Accepted try pk�tl`�,{1Date J►+sa <br /> Pet or Grout lnaf7eCteOn by ate Fwl Irsapeeirpn by <br /> Data <br /> Addnwol Co"wnanta A 4 t7J n' �L <br /> Applicant - Return all copies to Sax Joaquin Countl PublIC Ifealth Services l'D <br /> Soviroesental Aealtt Permit/Services J <br /> 445 S Sao Joaquin, P 0 DON 2009. Stka. Gx 95201 <br /> FEE ALLAOur�T Out AMOVNT R16AITTED x e RECEIV#D ay DATE PERMIT Pro <br /> IMF 0 CAS" <br /> . EN WNlary 100 b, <br /> Ir win <br />