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SAN .j(),%0UIN LOCAL HEALTH DIrTRIC" 1601 E. MAZE:-TON AVE STOC✓,fON, CA Teiephone (205) `'° 078+ > PFS Mtn '" �!:C ' `.'LAR FROM DATE ISSUED ° (Complete in Triplicate) Appl"t:on is h-c')y mads to the San Joaquin Local He+ith DiMkt for a Poffm to constrict and/or MrtM the work bonen doembed.Thb appBealldn la •nade in cMnprrn,,ce with Sar icoquon County Ordinance No.50 foo wwega or No. IBM fo-vel/pump and the Rulaa and negurtWo CO 00 Sm jew++r oQ Lor:a1 Nnah:n District. L Job Address CSL/-yo e--- X IQ CRY!'.��CZ4 Lot Sim�rPIM Owners Name _��—�i�s�/ Address /�/� ►Aar Gxnyectoes Namnf f -,--,t�4SS Lleanas No. 1._S-Y _ y ? _ Phone i�(r�. TYPE OF WELL/PUMP: - -NEW WELL U WELL REPLACEMENT Ll OUTf1UCT10N L1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER (3 j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO._ PWIP.Lon FOUNDATION _ AGRICULTURE WELL OTHISM WELL— PITNSUMPS it •,%� INTENDED USE TYPE OF WELL PROBLEM?-NA CONSTRUCTION SPIORCATiONS ❑ k1wetrfal ❑ open Bottom 0 Met•ao. aaof:Wall E6wwnon Dr.Of ww ca" —. i, ❑Don*s is/"-u Cr Gravel Pads rl Trmy TV"of Umm SPsOMIM110nE ❑Publk O Other Cl Deft Depth of ureal Baal TWO of CRNA ,t ❑Impaction _-Appeox. Depth ❑ Eaaeam Surface anal hrtol by Repa:r Work Gate ❑ Tyro of Pump H.P. Susie Work Dona We$Doetrictio.-1 ❑ Wall 0Wrfste- SaakV s'aterW:tap 5D'1 _ nspth- FU Ma"'.101 I I TYPE OF SEPTAL,AORK: NEW INSTA:.LAWN U REPAIR/ZoviON ir DESTRUCTION 0 IN.,aantk.ersasrnpwwdndd M publk aaMw b rvsaallI vvkhtn last.) r I?W*Pat:on will ear- Rasidsno,-Z- Cor..tl Number of living unit:,: -.[_ Ntxnber of bedrrw ms � Chsructa of yoR to a c,oth of 3 tact: C LA?' --1 —wow table depth_bn SEPTIC TANK lir�"/Ypt,'" �4!0d CRt tl No Caro«e+wns PKG.TREATMENT PLT.O , / M etiod of D*mW ''4ZA i; DMtanca to neanset: WON 2 O o myon O• Property Lkta LEACHING LINE M ho. 8 Laogth of Was 1 -1/o r Total NNnpth/else YD r 2 FILTFR BCG 0 DitUnce to naanrat: Well Ftwndallon !�� Proprty Lim —' N SEEFAGE f"7S r' )epn _ 2T stn. J/Yr Worttbar Z 1. SUMPS Distance to nor vm: WOE 2e0 ' Folxftft _.ZOO Isoparty Lina DISPOSAL PONDS 7 I hor%bp certify that I have propend this aptmoc"on end that Ow work wN be dorm in a000rdertus wHr San Joan ommy ordnanoM s' rMa.snd w rule and regulations of the San Joaquin '.opal IvWd District. Horne owrw of Roamed agent's aiWWura co tiRaa the folovAng:'T CwWv that in the pMfe no a of the wort)for which d*pal 2 Is bauad.1 ahaN rat _. vnploY any person In ri-ch manner as to Deems arbled to naro+lo m's comperwllon bona of CaiFomle."Canvoctors his"or sub-con sett slow"m cow dfles tie frllowirt<•''I ontify that in"m perfom wtoe of the wofft for v Jr-h Ihb peso In' I shM w iplOY persona aubiaet to workman's oompalow tion le"of C+Ylfomle." The applicant muss ccl for*111osquired know lye. Com Me climvAp on ti n= Siprttd x7r 7 LL4s — raw. Dtob• ^ FOIt DEPARTPA T USE ONLY Application AcM,od tri I'l e f Data ASM _ �l e Pit or Grout Insoaction Dv D.te �_ f9rtM Irr.p.adon br ossa �'�-n� Addhio-W Commons- -_ D S!h 4,6a Ml ❑ Lod) 389.3621 ❑Mantes E23-7104 ❑Tncy 535 • Applicant.Rafvm ave arpies to: Envirenmere*He.1 Psrn*/Swvkaa IWI E. Hasshat Ave., !'.O. Sort 2000, Stk.,CA BS201 INrO FFF AMOUNT DUE AMOUNT INICKTTID H RVAIVED By DATI 110" rNO. i fEN Isar Mffv.10/10) �-VIC 14 j-9-L, 4U(-1f r4 Yid,.