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f t A.PPLI CATI ON t'OR V.E"I T 71 <br /> ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC38 <br /> ENVIR0hNU-1LN 'A.L H.WALTO DIV16I0H <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PER &UIRHs Y <br /> (Complete in Triplicate) <br /> Application Is hereby ma.4t to Sa.a Joaquly County for a Derx1t tfi constrict and/or lcet&Ll the vork bertln 4eacrlbt4. n,SI <br /> ►pplICStloa Ia trifle In CCWIIance vltb 3a.n Jo..quln Co%i4Ly Or4:aaacc No. 519 Ln! 1661 AZA tEa RL.IeI " fle6VIA►L1o11i Or 5a.t] <br /> J04.4ula County Nbl7l`c lfc&ltS Silr�Yices. r� I <br /> ' Job Addt*t4 - -c-, NDIC �_��V-42- V__ City �D� ,. l.ot 31 ieJ�cresde t 0-5-kc," <br /> Owner's Nana ASD AdO,eu 221, .s..w 59;rrr-<,'(c I" Prone I.�oh c <br /> ' 17Ru�s ,TX 75zc1 <br /> :cnlrector �?f �Li� T.L 3A A S� Cel a R`7`ti snie No.�S7-G077Zo wonc 9 i& 'ZSZ 745 <br /> �drets 112 S .,nom �C <br /> TYPE OF WELL/PUMP. trEW WELL O WELL REPI.ACEN!EN'T O DESTRUCTION O Art of Service Ve:I ❑ <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER 4,-D�torl^4 We <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Ft O. PROP. LINE <br /> FOUNDATION AGRICULTUAE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PAOSLEM AREA CONSTAUCTION SPECIFICATIONS <br /> 0 Indvivial O Open $;horn O MinleCJ Dia. of welt Eacavit4n D4. of Well CBstnq <br /> ✓•✓ Dameu;c/Pr.vals C, G+e.-d Peck (7 710cy Typo of Css:n4 PVc Sprc;f.ca1;one <br /> ' 0 PubGt 1:1 Other Q Oarta Depth of GIOVI Sea{ Type of Grout <br /> Ci trrrpatron , __._ Apva&. Death ❑ Eallim Surface Seal Insfauad by <br /> Row;r wo+Ir Gane U of Pump .r— H,P. State Worn Do" <br /> ' WowCHatrvction (� Wow DisrrH'.er i�� Scalin4 }ht.erI&! i Dcpth n <br /> Depth ?Mer Wt.erlal 4 Depth <br /> TYPE OF SEPTIC wOAK, NEW INSTALLATION S] REPAIR/AODITION i'i -OESTRUCIION Cl INo s4pl.c System pt'rrrvrted if auDIK S,vml ,r l <br /> svS.l�ri:d w,lh.n 203 feel.) <br /> go Inalallitipn -411 Serve: Aosid.ence _ Comr*yrcist _ Other <br /> Nvmbei of tivir+q units: Nvmtw of b+Croorns <br /> Ch4ra<te. of Soil to a d+pth of 3 fact: Water ubta Depth <br /> 1 SEPTIC TANK 4 Typelmfg Cipactry No. C0'-"nM*nrr <br /> PKG. TREATMENT PLT. n Method of OispaLal <br /> DL&utvA to r+tirest: Well Foun6ar on Property Line , <br /> LEACHING UNE 0 No. b Length of ILnes Total lengthlsuts <br /> FILTER BED n Durance L7 r.4tWl: Wall Froptr:y Line <br /> I <br /> SEEPAGE PITS f I Npth $J♦ Numtrr <br /> SUMPS LI D.&lirt•cs to f aereat: waf•' Proporry Luw <br /> 1,D)SPOSAL PONDS O <br /> hereby Cen.y Chet I hive prs0ated Ihi7 SPI)k Inn Ind !hit the ,,Ork w.7I be done m ACCQ',14 +Ce vvilh San JoaQu;n county otd-ninces, slate lew'e. 1.'14vf.a end rewt,t,ont of rhe San Joagu�n Cp,;nty <br /> ► Oma owner or f canned .gent'& aignslure COM441 the tpilavv.r+g "I certify thal in Ina perlC.rTar•te of the work fW vn.ch tt..s porrr%t 4 .siva', I "U not <br /> r^p:oy any Fyson i7 WCh min".er aA 10 t»KOTe Wbrect 10 workrr+jn'a C4mapr au0n taws of Cad 0trAe." CO.titractor's h.r;r+,Q or svt?contract;ng a;gr.a!ura <br /> art f;ea tM roltor,inQ: "f certify that in the peffortr4rvca of 0A wotl for +•T;Ch this porn;t is iuve4. I sruu ernpior paraani iv5;ect t0 v orkn%&n'e corr,�ensj• <br /> ion Lays of ulfornli." <br /> The spokint &Gal CJV'401/11 t.gv-4.4 irurs;t+ore. Cam.pta!e draw:n9 on averse Side. <br /> nod Tills: oils: <br /> rOR DEPIIRTMEW U8E ONLY <br /> POItcslion Acca01e4 by Dau ArN <br /> Orout fnaPa.Chon by Date Final Inspection by Oita <br /> d60nif Cornrnents: <br /> lletu; - getUM &,U COPlea Co: S►.Y JOAQUIlI COLN-ly ;1VALIC V=778 5"VIC9S <br /> LNVIAONwExrAL ]fXALTd DIVISION PMIT/31AVICE3 <br /> <IS N Salt JOAQUIN, P 0 BCLX 2009, tJT'CICXTCK, CA 95201 <br /> fff AM0u+•T pt;[ AuGUNY wEu.rTfl) C[ 1tfCfrvtO DY D•tt rtokvoT',v0. <br /> Iris O C <br /> .}l� IJ•ry <br />