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ryezmm <br /> �EMSE <br /> AppLICQTION ICOR PURUIT <br /> SAN JOAQUIN COMMY PUBLIC HSALTH SERVICES <br /> MVIR 'AL HE-,LTR DIVISION <br /> 1601 E. WBLToN AVE., PHONE 1[2404973-8420 <br /> .P 0 BOR 2009, STOCLTON, CA 05201 <br /> Completta in Triplicate} <br /> Apylicatton is herot:ar taide to Ban Joaquin Co=tp for a yarait to eooatrtwt&Wor imuLl the vork bereta deaoribed. This <br /> syplAaativa to mAe in aoepllsece vith ass.Toequin Coud%y Draintmg.aro. 5k9 and IM end the Ru1ee and fletaulatIms of baa <br /> JoagniR <br /> lan4L• salt4 �107 2=11s" <br /> JebAddmut ; arl <br /> Ciry�yt 1 Lot alae/Aoreege <br /> _ fameR AddrHa/�. +y.—�Ct 4 moo! Phase <br /> CA <br /> Ownee'g Hnme <br /> 10!11 r+sEMAn ihre., ych10 .77p <br /> Cenuatin r Ayorddresi CA- Ltcgtlse No. PnOne <br /> E�OF W LLLI UMP: N WftL Ak Ypypr ,WILL RjP CdMflHT 0 D98TKt1CT1oN Out of >fsry TO97—C <br /> PUMP INSTALLATION 13 � BYSTEM REPAIR 0 <br /> OTHER 0 Moaitoria�tial! C3 <br /> DISTANCE TO WREST: SEPTIC TANK S R LINeS DISPOSAL FLO. PROP.LINE <br /> FOUNDATION A(IAICULTUffE WELL OTHER WILLica(L PmisuMPS _ <br /> _. IHTQNbEO USE TYPE OF WILL PROBLEM AREA CONSTRUCTION SPICIMATION3 N <br /> yypr <br /> 7'-'��.,,4.1 IAmtrio 0 oto Bottom 17 Mantsae Dia.of Wei f�:errasbn._.�1u ora.al WNI C4tlo4 8. <br /> �""'f DomaadelPrlvNe �1 Oravte Petk M Traey TYRO of cetktg Se I' 4m Ptf SpaelRoatln^a <br /> W) PI Pubis 1"1 Dlher n dalra Depth of bloat$eal 92MA 7troe of 0 <br /> 1 I tedoclon 3 ditiCJ j r t"Approa.Depth 11 Eeslem Burfaaa Beal mal"Ad by 6AIABCA , <br /> Rapeir Watts Oona 0 Type of Pump H.P. Bt lq Wgrk n &� <br /> 71 lelit%atmrttt0. „Wed Demtadn 0 WIN os <br /> f�,10 <br /> OaVrh filler Matet!ial 8 aapah0.?LL mi J <br /> MPTUFFM WORK: NEW INSTALLATION I 1 IJEPAMIADDITION I I DESTRUCTION I I WO aePtk aystom parndssad 9 PuWk MtvW ie <br /> evaiinis witttfri 106 fa1.1 <br /> lumisdoo wEl s ww: AtWorv:e^ Cammntial— Otkwt <br /> Numbs d Mag solute..-- NumCet Of Dadtoaf m— <br /> Charrctar at gob to a depth of 3 last: Weis`tette death <br /> SOTV TANX O Type/futfp Capsalty.• - No.Cotttparlmst tv <br /> PKQ.TRIATMIHT PLT.Cl Mao"m 01600" <br /> DIVJWA to nwreait Waf Fotmdrldat Ptoporty Lim <br /> LEACHING LINE 0 No.a Length of tinea Toll)tengthl** <br /> FILTIIR ego Cl Distance to nmtnu Wets�� Feundadmn Pr peRY Lkte <br /> SEAPAGE PITS I I Depth .Sits NUMAW <br /> sumps Ll Disterwa to nwom Wim Fe odatian PraplAy Ll" <br /> DISPOSAL <br /> —�— <br /> DISPOSAL PON6E 0 <br /> 1 t weby tartlry Mat i have pr*auW this spptkatimn and that the vrork will Its done in KCordance With Son Jeagwn county 11dittamm gest+W4&mw <br /> rules end tegttkltimna of the Sian Jakukn Catesty <br /> Hartle awrtsr or!ceased+genre dg Awry c wtion Iha fotowing:'I t:*rtify dut ko tho N dormsnce of the Yrak 1a oAdch this 114 t k .1 aldol etas <br /> employ any poweam In mucro awu%r as so become sit to workman's van4mmsom lows of Cilllornim."coetrames hlrktg or Rub-mantftl ft aipnahnn <br /> cartn"the fobwfng:'•I eowy that in the poloemance of the work for%0"thio 00ONt is faauad.I shay wa0w par6wo subomt to tvO*"%tt'o aaenpuaaw <br /> dor 4Kw of Cal616nAl." <br /> The applksM ohNl Balt for M required lnap,cdws.Comptsla drawing on mmea side. <br /> Sired Title:_�,srtdwl isT Dgts: MAO <br /> /9 <br /> _ FOR DIPARTAIINT USI ONLY s <br /> As,plkatbn Accepted by Date._ —11 Arno <br /> Pit or Grout frapeetlon by Oat* Final hupeatlen by <br /> dditlOnOt comments: <br /> ti.._.grpllcant—RHeturA OU aoFiu to: Bea Joaduta COUM"310 Ir alth <br /> Serrtaes, Ravire®aatel Eealth PoradtISAF imoe n �r/I !!! <br /> 16M i. Iaaaltoa Aye.. P 0&mt a Stockton, CA "201 /— <br /> tHl'n AMOUNT DUE AMWNT AIMITTf9CAH � �I Io by DATE PIRMW.NO. -- <br /> N l}fi Iltly.lr,tsook 7Q 1 ZAJ <br /> _tttafa b 'd av:G1 26/90/10 WOad <br />