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w APPLICAT 7..aRl SART JOAQUIN COU" PUBLIC EEALTH SERVICES ( ! PEVVIROMEFTAL HEALTH DIVISlow 448 K SAN JOAQUIN, PHONE (209)468-3420 P 0 Box 2009, SToCLCTO?4, CA 95201 ��.�.,,, .8 I:�Y.14A�►�V?�C�tF�J 1J� � . �OSDc S. �j`/' (Complete in Triplicate) IiiglScat3�et is laarelry tanCO ;an Josquicl County for a• -rant to Construct and/or Sttatell the work herein described. This ttprplication is MAO In COVVa cake dit"t r4&JcrAL110 Cou v ordinance ro. 549 and 11562 and the Rulca end Re"tions or sea Joarluia CotsotY Asbllo Xealth Garrieea. Job Addraaa 1j0jtX Sear r^ar ,.T'roc W C01t4-'Ar•ti o r/4"t Cnv Tr a_ tY__._. Lot Sae/Acreage /l00 acre,/ , OwtMrsNefns,� v (or ►a� n_AAddressl�(�. far rQ. T'wcY7. r 9a a7y Phon�an4�tSC'-3�t/O g Cant,atta�r✓tS� dd.ef •if o. a A�.+Rf!171#01f!171#01C 67 . AWC Cor'`/c"''LLkense Mo.`g'�979 jsftone/91(, tf 3l-7J716 P;JF WELL/PUMP: NE'oi Wj,.L S9 Wti.i.RC?LACEMENT C1 ^-------------+ DESTRUCTION (.l Out of rviCe all PUMP INSTALIAT Off O SYSTEM fl^PAIR L) OTHER O %Ieoflitori00 WellLt LI DISTANCE TO NEAREST: FJSPTTC TANK. SEN/ER LINES �!ror �+a nt DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE_WELL OTH£R WELL PITS/SUMPS 3 1114TEN0110 USE_ TYPE OF VOW" "WILIM AREA CONSTRUCT"5PfClF1r„ATI0NP -- Cl frtt tiaS ! Sfaranm C Y an a _ a, I r:f auriaim, %/- Due.of WOO Casirig c L 4 fI'1 Donaetb/PrlvsRs Ct GrsvN Peck fJ Tracy Type of CtINfyTf SpecAtcenosa�'•Cl&"c/el`a 40 ''lh�ae th Oer 1-I Dena De"of Grow Uill l�F.r¢�r ir.. Type of 4. O:ovt,�•'wv�-brYh„fir wig~ Aftplaa,Deprff t 1 EnatoM Surfs”Send IWAIled by W ft f Il i fbPNr Work Cons U Typo of A -b--r.—1+"Leif �r; 1 C9 p M^ State Work Dote Whll Cle11luetkrn O W44 DFarneter ea IW4 Hatarrlal A Depth kelt!-r'&.�ex1itL* j OspAr 71.1.1er/SltLeria�A DeytTi �l1LC.t. SQ e� �''1 f r r�Prt r 4"f'F'0 4r Y E Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITtON 1 I DE57RUCTION I t INo 1MPtrc system permuted 11 public asuver b C av l"We within 2W leet.l 0 Inatagaeiort ala cera Aesklanee_ Contrtlarcisl_,_„ Othe, NU`60 of Ov(ng finks: Number of bedrooms Charaeter of coo to a depth of 3 feet: Wour table depth SEPTIC TANK O Type/Mfg 11( PKG.TREATMENT PLT.O CApaGhY -- No.Compartment _ +f Method of Diapoaal DWAnice to nearest: We" Foundation Property Line LEACHING UNE 0 No.A Length of lino Tout length/size DED O Distance to newest: We!! Foundation Property Lins SEEPAGE PITS 1 I Depth Sirs ` Number SUMPS LI Mance to nearest: We!! Foundationpr DISPOSAL PONOS Q oPsrty Lino_— i hereby certify that 1 have prepared this application artrl that the work will be done in Accordance with San Joaquin county ordinances,atsu taws,and ruL!a end regulations of the San Joaquin County Hanle owr.ar or bcensad&gent's signature txrtilbs the foliowtng;"I Certify that In the performance of the work for which thts pernrt is issued,1 M.Nt not employ Only person in such ltlannnr as to become subject to vvw4mon's compensation laws of California."Contractor's hiring or sub•contraeting ugnahie certifies the 1090wkV:"I CO(Vfy that in the pertormance of the work is which ihia permit Is issued,!shall em to tion laws of COIBomia." P Y Persons subject 10 workman's compenss. The applicant must�iurfl for all required inspections.Complete drawing on reverse side, Signed x iE Thb: =+Lt'°fr;t---Tr-Kr ro — Date: FOR EPARTMENT USE ONLY Applicatlon Accepted by � Date Pk or Grout Inspec'on by Date Final Inapection by / r - Date Additbnal Comment: `J Applicant - Return all copies to: San Joaquin County Public Health Services Euvironmental Healt.b Ptratit/Nervicos 445 N San Joaquin, P 0 lion 2W9, Sthn, CA 95201 FE;' .,LuwNq DpF. AMOUNT REMITTED DAPS p(RMtgNO. tNfO ylek RFCEtV[D AY �y — . EM H er.13.24 Y6 taEV.tr A Otlf(J �• )( C ! t� /t7 !fi A111/ �^ _ °---/`! (� � Et -