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;ih\ JOr`f( UIN CUUNTY IfUBI-IC; 111tiA.C,TI1 :Sksl1Vi: 1•::i
<br /> ii iN V I ItC)ilrssl ii:."1i TA I-, 11F A:I,'1 H DIVISION
<br /> 445 N :iA1, .101:QUI1N, IM(A.Y.IA \,`'i 3)•3s t3-:?A::U
<br /> I' U ;C)X 20&D' ;-:0C':K'.'-0N,y6 CAtt �jjl5201 (r�`
<br /> �.!•,. ��>`'Ltisi4i '1L�A.3.rJlif' ,fkl 1r.21{I1 Ls1.1
<br /> lt:umplete In Triplicate)
<br /> Ay+a?itat ton, is s.•rPPy fmce to Tia:+ Imiquin county SS,r a porm.t to cont,t rust and/or Inata.l the vork herv: d•iorri oed. 'rhia
<br /> a;,i;.I;.t 1" 1a auBP }n C"VTI lanct vi t\ Ban Joa`uIn County ord:nance no. Sig and attQ and the Rulea tlld N.a lat I,one or "n
<br /> Joa1ula county Nblic fltalth 5ervicea.
<br /> r
<br /> Job AAw..;; 1 / (I..n _r..v i.�.�--.�' \_,�.._..___.. Gry
<br /> --•.�.r) . - .—_...R._.._...._
<br /> Gw,.wank+me .�I�S.��{��_.�_{.A.�,1�1"i��J,._.__.
<br /> f � "
<br /> 1JJ ( / ,/ l
<br /> C�nt•Icicv j_f S:.`_�Y:_'S.r_`,S�_r.�..f .__A:1h•tt_%_t,/,a'.. _1�,,�..�.r,^__ .r'.__._..1- -Pnfr No �8 Ja,LJ--Phone fj--�t�•'<,'��
<br /> TYPE OF VikLLr1'UM? NEW WELL %I %YELL f1EvlACtMINT fl DESTRUCTION i.1 Out or Service itny'1 i)
<br /> PUMt'INSTALLATION i SYSTEM REPAIR :I OTHER Ww..ltorint( Well C7
<br /> DISTANCE TO NEAREST: SEPTIC TANK JCWER UNCS � DISPOSAL FLU. PROP LINE
<br /> FOUNDATSGN _ AGAiCULTl1RE WELL _ 0711 R WELL
<br /> INTENDED uSd _TYPE OF WILL PRODLEM AREA CONSTNUCTION SPECIFICATIONS
<br /> Il NWustfNt U Open Bovorn C)Maniac• D-m.of WW EaatroWn Dw. of Wet:Casinj --d
<br /> i I Oases ic/Private ❑Gravel Pack ❑Tracy Type of Casing_ 50scda;atwn: I
<br /> i'I Ptrbke Il Other (l pelta Depth of Grow Seal Tyles of Grout \
<br /> Irrgyai rrrf Approx. Depth I I Easiern Surface Sual Installud by
<br /> Rappr Work Duna LJ Typo of Purnp N P. __._ _ _ Slate Work Uarw
<br /> Wee Destruction J Wag Dismater 0"llnY MAWrlol ♦ Ovyth j
<br /> Daplh F1Ylat• HaVarlal d Loth �_ a
<br /> TYPE OF SEPTIC WOhK. NEW INSTALtAIJON KEPAIAIADUITION t I U¢STRUCTION t " 1140 tupuc ,ytiem pfirwattod t Wrt>ak waver is
<br /> t j { // Ir ava"bW within 2W las:.;
<br /> Instaliar,on"stow. ResidenCu T Coriv n4tcial-1:1 Other
<br /> F'•rntbed of Owing touts: Number of befdroomo
<br /> Cttarwctar 0 sou;o•o,sE,th of y feet: / Waver tanto oropuf � (Y
<br /> GEPTIC TANK Type/Mid i +%•' �.-:��y.�,�„_ Capacity�lJ "' '� No. C:im;.artm-n;a
<br /> J
<br /> PKI3. T012ATMI NT PLT.Cl Y.' mri;wd or D;apou;;
<br /> i y�
<br /> 4.•..•, ..:. to ryai
<br /> aru : n' �.� iowWatan r.' P,opansty lu
<br /> r J
<br /> tEACHING LINti '{i1 No. to Length of t:naa ._. tt�. ,),...�..,�._ Total tangir,(erxe..
<br /> FILTER ESLD C) D.ofrv+ee to noarasf. Wca L' �� Frwr+Gsnwn—1 Fywpeny LaW i C'
<br /> SEEl'i PITS Depth t � 1.iNumber
<br /> SUMPS t.t Distance to near";: Watt
<br /> 1FuurWaiwn Nrup.m/LNia
<br /> 019POSAI PCO41,6 i'' __
<br /> I Pwraby certify that i peva p.aptrra;I In,r rl:)pIr{anon end ihm the work voll bo Bono in accordance with San Joaquin c"my ordinzricoa, otwo Wwt, and `
<br /> rules ertd rag4tations of the San Joaquin County
<br /> Hwa OWnW Of!Ksrued a-dent's iiyna;tura LtfinihrJ iha "1 ccmiy trim in the pwiarmanco of One ^ork tot whit.'+this pe-mit it"tvuad, i shalt not t J 1
<br /> employ any,pwlfon M such rrwnnsr as to ifecorna mibjoct t0 workman's Compenaenlf+i UWa of California"Canireclor'e nn NO or,UD{GnireChnp 61gnZ;ura
<br /> cwtffies the fosow rp 'I CMTty that in the ptrforrmarKe or tha work to,which this permit to iNuad,I shad amptoy po,%ons aublect to workman's componsa•
<br /> hon wrm of Cakfornla.•'
<br /> the appEicar+t m of tau for a1i rugt:roJ in" lion Conip+ct9 israw"np on reverse_side. t'
<br /> 1 1
<br /> W
<br /> O OCtPARTMENT 1.18d ONLY
<br /> Appil"ifon Acic"ted by
<br /> ►If of Qroul Irfepetton by ___ _� _� Date Final Inopaction by_ Date_IICIL&
<br /> 2.1
<br /> A , f f
<br /> Additional Ctfmmenta: Prw,4. C�,•e.,....��.._`��Akl.. 1Te�..11f�f•,uRi)?_.R.u'wA.. �_ [�1 "a r��ja:
<br /> Appitrti - Beturn all cople" to: San Joaquin County LIWAIC tt„alth Servlcoa
<br /> Gnilroamontai Iloalth Pertolt/9Rrvlcaa Awl
<br /> QOf. v San Juarula, P 0 Mix 96Vi7, fttkn, CA r45701
<br /> Vi C ---r--+.....
<br /> I ir:rU�Aa"D�d,T Diu; I AMCIVNT A(M-TTED 1 �':i't NrC2"VeD 3iy 1j pATQ� PERMIT No
<br /> NO
<br /> �
<br /> RN 1)i.IaIV �r.ai"'fi t 1 -L-...{.r/ ` •�,l �Gl', ._�J (`
<br />
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