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f t hQPLI CATI ON l'OR PEICM 1 T , <br /> SAN JOAQUIN COUNTY PU13LIC HEALTH SERVICES <br /> EHVIRONWiNTAl. III;ALZ S Di VI SIGN <br /> P O BOX 2008 , S1`OCKTOn , CA 95201 <br /> (209) 468-3447 <br /> _� -- YELL FRN )` TZ 15S 1KD <br /> (COMPlete in Triplicate) <br /> ARPlfcat:oa I hcrc y tca4c.t.o San .rcagvla County !or a pernit :d+ eons t-: c; nadlor lei tall the vo;! 6er<1n deacrlbcd. ThS• <br /> 044v at O le rode 1a coIglf54r- cc <br /> Sea Jc;yufn Cooazty OrC7"oc< 1ro. 5-9 4n: 11362 a� tta RNLJcP sag 1tc9v!Atlor.A or ,5&Z <br /> Jor.gvlc Cw.aty P1,ib11e RtaltS 9-e�r7Y;eta. <br /> 1 Job Add+eet � ��3iC T . /iT�N City _ LOt 91 tc/,t:re{.ze:-41, S q., ` <br /> Ov+ner'a Nara Add,ess �L� .� �`t.lin x� S.. <br /> . 1 -f3� /�—�---�-rtx'C._._..� Prions �ov.e. <br /> DnouAs ,TX -751Z1- <br /> =Gr1lriCly/ 7 A�dreSt IIZ`7s �.rnrhr {:01��,. ? �•ey zC+L;C`D It l[D.(-'J-7'-GO✓ 1 $SZ S <br /> 7Zv P-ane 9 b 4 't <br /> TYPE OF WELL/PUMP. NEW Yo'ELL D VtrELL REPI.ACEP.EN'T L) OESTRVCTiON ❑ CL: of Service ' 1 1 0 <br /> PUMP INSTALLATION5Y5TEM REPAIR :] OTHER "FcDAtcrIrr Vcll <br /> DISTANCE 7O NEAREST: SEPTIC TANK SEWEA L1ti4ES DISPOSAL FL0. PROP. LINE <br /> fOVN0ATI0N AGRICULTURE WELL OTHEA WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PA08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> indurrryr -� D Ooan Bottom G A.[snt►ca Cl;a or Werr Ercavaran Dv. Of WoI1 <br /> Ca son <br /> L q mesrCrPrrwta [? C,swg <br /> r Pick F) Tracy Typo or Cas:nq PyC <br /> 5Y.cif:cations <br /> P„bit C) Other D Datta NPIh o1 Grout Ss--W <br /> TYp+ of GrovtQn ,,!Cl.r , <br /> CG lrnps+ron Apvoa. DeD:h D Eatlsrn Svrfaca 54ar InsiaUed by °� &r4r'k1.' <br /> P004.1 Wort Done U "TYD{ of Pump 5laa Wort D:x+a <br /> Wall Doastructio-n �• Welt Oisr:uitr '•�L !�T Statins }4ateri� i DC�tt, <br /> Depth :f 1Y13ar )6Ltdv1&1 4 Neth a' Iry <br /> TYPE OF SEPTSC WORK. NEW INSTALLATION 0 REPAIR1AODfTION i"r OfSTRUCTtON ; INo sepr,c sysram perrn,tlyd if put)tc <br /> sa.ti,cr ,: <br /> [iflati{,n will t4”. Rayidant{ _ Cbmrryr�iat 3vi,Iit?:e "rhrn 2W ltet.l <br /> 30.n%b*f of Ivt'N units: h'urnber of beCr <br /> Igor.r <br /> ChirACter or 6.0' to s depth of 3 ("1: <br /> 4YAttr tbhk deDSh <br /> EPTtC TANK p ryQerMrq CAYrcrry <br /> tXG. TRE-ATMENT PLT. [1 <br /> PMethod of Dm,-.0 st <br /> onca to ++cart-lt: WaL Foundar�on Property Line <br /> 1EACHING Lltig [] Na. b Length of tines <br /> Total langrh/airs <br /> FILTER 8ED i:7 Distancb i� near'rsi: Well Foundation <br /> --—_� Prop-ony Lina f <br /> EEPAGE PITS I I Depth Sur I <br /> tr,4iP 5 N�mb..r <br /> ump5L Lt DisIanu Io r+.64raet: W" Fow,dsl,on Ptpp try l� <br /> PONDIS p <br /> raby C011-fy that I hsvt Drtpsiv-d this apDricstron and '.h2t the wall <br /> lawrit b* da.ye rn aCCarainCa with San JDA uin COuns And raguticiOns of tht San Joagvin Cvvnty v tv ord•nances. Slits bwt. i sd <br /> ►toms Own{r or 1Lcerstad agent's s+gnsture cers•f as IM h�rlow n "f <br /> floy any Porion in g Conry that in le"t par:OfminCa of the wort Io.? o^;Ch Iny rrrk <br /> wch rntf+�ar st to becorn{ avb c1 10 wootrn n's wm f 1 c u ruut>+, t AQn not <br /> ri{s try rabwin ! 'Jehis P-dn 4w1 Of %Al,tprnlG." COatr{t10!'t horin� pr sul}COniraCGng s;gr.A!urt <br /> q: "E ctrtiry that rn Iris periarnanc{ of rIy wort for which this per,-nit rs auad, ( s'uit emPIpY pecaOnA 1vb;ect to wortrnsn*s corr�ans.s. <br /> 44vs o1 Glirorn4." <br /> Tht Applicant W'st CJp.re.M regv1"A.4 Ln4w.1i0r.a. Co,Tp;e!a drawing on reve(w aide. <br /> PAW X <br /> rOR DEPARTMENT USE ONLY <br /> I,celion Aceespta•d by . <br /> rout Ina.p.<I;on by <br /> Dots Fins) IMpeclron by <br /> Oils <br />� s[ Comm-,ants: <br /> licLnt - °e Lura LLL copies to: 31.N JOAQUItI COVXTY PUBLIC HX LTB 88RVICSS ` <br /> LNY11RONVExrAi, 1(EAi,TtI DIVISIOx PF.1l111T/3ZAY1C93 <br /> 415 Y SALif JOAQQJX. P 0 BCX YOGA, Y WXTCH, CA 65201 <br /> YEE <br /> Irr►Q ALtOUi-T (JV1 --- AIvGVN? AEr.1,TTfO CK <br /> CASH AECEIVED DY OArE _ f(r.ar,T tip <br /> vlr[v .•r <br />