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'APPLICATION F R PSR1f I T � f 7_tg jy . <br /> SAN JOAQUIN C013=- PUSI. C HEALTH SERVICES !!�� fl <br /> EMIRONM1®ITAL = DIVISIM _ <br /> 445 N SAN JOAQUIN, PH E (209)468-3420 E 9 19 93 <br /> P 0 sora 2009, STOCITION, CA 85201 <br /> ENVIRONMENTAL HEALTH <br /> (Ga>;apJ.ete in T iplicata) <br /> PERMIT/SERVICES <br /> Apj�liCatios is hares nada !A Sm Joaquin C&=tr for a permit to comstruct and/or lasts.LL the work herein described. 'Phis <br /> aybiicatifla is Mads in eanpuaMee with dna Joaquin County Ordinsoc• No. 549 and 18" and tb, Rules Mad AagulaUaso-or San <br /> Jasgeis 40UR Ir POUlis ilea" Srrytoes. <br /> Job Addrsw itv Lot $&ss/Acreaa,N©• �GP�g. <br /> owrnar'. (,`tLLS 1 .,&Rfho 6A.4K Address 33 S•C`'R � 9� LA. hon. ' ILs3-3$Sa <br /> CanlractOrL LAS'C4J tgkl1 k8t� . Address 5q IRS C.po)()t2fa ��o License rte. Phttrns�ILF <br /> TYP!OF WELL/P IMP: NEW WELL ❑ WELL AEPLAC MONT h DESTRUCTION ❑ Out at Sery:es Hall <br /> PUMP INSTALLATION O SYSTEM [PAIR ❑ OTHER X" "Glallor vA tfell C <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP: LINE <br /> POUNOAT'ION AGAMULTURE WELL 0TN8A WELL - PITlt/!SUMPS A) <br /> iNTENOEO USE TYPE OF WELL PROBLEM AREA CON>STftl1 TION SPECIFICATION .3 <br /> n Indwwo 1 Open donan XMMZ Drs.of We Eacaumoon Dia. of WsN C"ft <br /> C1 Dort WmsiPriwle © Oewst Pack ©Tracy Type of C& ino_ Speflific bons. <br /> 11 Pntbsa n 0100F rl Cwta Depth of G ato Seal Type of Grout <br /> i I trriwim ..,..Al pre■. Depth- i ! Eastem 8udsee 96-1 Inatalleo by <br /> RspsM War Dohs L] Typ *Pump H.A. Stats Werk Dora <br /> i <br /> VMOeeNlMtbnt VVsE owrA tr` L ". (, I�Lfrlal Aeptll s� I <br /> Doom—­10 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I AEPAIR/AODITION t I DESTRUCTION I I IND sspttc synerrt OMMinsd d public sewer is <br /> awsilabie within=sen.! <br /> Iraeft An ww sennet Rfaaidsnm— Conw wolat— Othw <br /> Nwdtw of Y+Nrro units .. Number e1 bsdreonn <br /> charlaw at am to a dna Im of S fwL. wins Rabic depth <br /> SEPTIC TANK ❑ Typomog cavocky No.COmpwtnrna <br /> PKd. TREATMENT PLT.0 110191hod of Dlaposm <br /> Olwsnce w go I : Well-- Foundation Prppsrtw Lhtw <br /> LEACHING UNE L1 No. •Leftpth of lines Total Iatgth/sive <br /> FILTI4111 OEb C Dlstsnes re►tyres: Wed Fe PMOWW Line <br /> SiMAGE PITS I I Depth 8999 NYumbw <br /> Sumft LI DWsboe 40 Awrestn well Fewtdw in Propww tate <br /> 015MBAL PONOS ❑ <br /> I hsfeby"nrfy Ihel I hers gapared this sppli mkm and thin tris worst will W dorm i in accordance wish San Joaquin county eroftenoss, s"mIourk and <br /> Mo attd rftgwoliens of the Ian JG"w t Canty <br /> Monne ewrw w ticordl d aparit s signature oerURss tM Wa ww*: "I Corrily,that In 11 to 004orrnanos at snit work for which this Permit to wwrsd.I"not <br /> --oby any PIMP in auehsublsot to wvrsmsn'a c0mpenss laws 01 California."Contractor's hiring a sub-convartlrto signature <br /> asrtlNse the faNerrintg:"I as sit the ince of the work for whkh I his nna is issued.i&hall sm0ay persons subpot to worrman's eorrnponw <br /> tions Catlferrrls." <br /> The can fsgtrked Cor"O"ti drawing on•ewers, ids. _ <br /> Signed 1 �h 0el 14 1 C k' <br /> Tine: t� `` <br /> i�RGo 17 FOR p9P'ARTl1EENT USE ONLY '} <br /> ;IlppMsation Aoesgte0 by bata� Area <br /> Pit or GPM Impel, by Data �3 Ffnal Inweal" by Gats <br /> AddMlanal Camwwft- 6/ -�-3 71 10" <br /> Applicant - Return all copies so: Baa Joagttiri County Public Healib 8arvtces .,ter` �O <br /> gavircumarntal health Po 2 Permit/Services '� <br /> "a R Baa Joaquin, P O baz 2000, Stks, CA 98201 <br /> AMOUM1T DUE AMOUNT AIMITTI10 cat tAlN RECOWD sV DATE PEItIA"'NO. I <br /> IN 1iEE IRtY.va Q : , <br /> !M q+i <br />