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f . <br /> a, <br /> 114 <br /> 1 <br /> APPLICATION FOR PERMIT <br /> BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL UALTH DIVISION <br /> P 0 SOS 2009• STOCLTON, CA 95901 <br /> (209) 988-9'w j'iJ)c t <br /> (Complete in Triplicate) <br /> AWICetiee is Mrebr mms N Bea Joaquin County for a perw t to construct and/or install the vorR herein described. This <br /> "pateetla to ••tale to Compliance With Sea JwAuia County orditWtee No. 1`9 and 1562 •M the Attlee and Regulations of Sae p <br /> Js""s County Public u Mtrvie• <br /> Jab A00044, City�F+i Lot els•/Acrs+wye <br /> 4 , <br /> tr <br /> owf1B/1 �* Addr•ar R •amtF Mrs <br /> y' Conlrra;l Add14t1 �� Llclnte � � `„ <br /> NEW WEII O WELL REPLACEMENT !-1 DESTRUCTION of Service ell <br /> LL.. ....: NonitorinS well El <br /> PUMP INSTALLATION O SYSTEM REPAIR � OTHER <br /> 01%yANCI To NIA-RJST: SEPTIC YANK SEWER LINES DISPOSAL FLO. PROP LINE <br /> FOUNDATION AGRICULTURE WELL _-- OTHER WELL PITS/SUMPS <br /> MITIN�" TYPE OF WEII PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L)NtMY9M* O Open S+Refttiehen+ O MenN►ea Die. of W@4 Ixesystwn Dw of Well Cs" <br /> ;.1 E1MaM1N/PNvsN O awe!Peak O Tiny Type or Cssitq Spaciliutrons a <br /> Ak n o" 00014 Depth of Grout SWM Type W <br /> Q P <br /> at �0/wn AN—. Depth Of SvAioe Seel Installed by ; <br /> 111MIMB OMM t] Tale N Ptltttp H P.--- -- State Was Done_ <br /> Sse <br /> llaS Itsterial • Depth LA <br /> �: UVIS OBSIInB11Ett O Yllq Olrttww —.._..�.- , <br /> �* Ulla' Neterlal M Depth <br /> y ALI,A 1ANIMOO1TtON LIESTRtICTION IND aspic system pstrtwtted N ptblit:Weise is <br /> w•r1•b*w thin 200 feet.l <br /> �I wtoo M"we woof MNMM MMMM11w.- ! <br /> z�^: IIfMMS►N EWk"S tttttNb: i <br /> a " W14r 1•b1•depth <br /> 1MS�IM N IBS fe t Mit N>y Ewa-.�........ i <br /> A "'' C•peeNY No.Cotnpatlftrnit <br /> t1 A O Method of DMpo•0 <br /> W4 lq�%Iww PLY.Sl <br /> r% ftw to to t&.1t. WN Founodstion ►t0petty line <br /> LIACIMM IMM CT Na.•letpth 01%A06Total lsn9th/site j <br /> FILTER•1'D 0 Ows w*4 ftnw*d: yybR Found•twn Propetfy Sins <br /> ARII"AEM�{� i I Depth Stn NumbN <br /> Kept` LI Otneftee 00#140011•F WONPeundMbn hopeety lie <br /> T ayr .$ 1 MtBt!M11M1 MIM i fwe pN•ted"•Ppaceiron and that the www will be dons in seca3anca Wwth Sen Joaquin county etdtnanen,ae14 tew•,end <br /> x" 2 11189 wd NOON**M IM Sen Jeepuih County <br /> ,,: ;• •f B M �„ty tetute ow-five the foaaw np "1 tornN that to the parl0rmence of the wort tot Which thrs 1;4,tw is nsvd.t the, <br /> not <br /> ?'.`"'`� - ''BBI(MB�91tF •tl•h"1011101101 M to h•eana eybtaCt 10 Wpr�T•nY companMaon taws of CaMlatnla."COntrattoes Pwinp a MltfeOntraetiflp tlgrytvrrr <br /> iBf w 11 ear"eat In pal VA of Me wan Not hreh this perm••is Wsou".I Ownemploy persons subfaet 10vWOAryt•n'•evtnpenw <br /> + Tft ptttlMB C Me <br /> Title:\>j/ Oe»: <br /> IPA,I►MINT USA ONLY r Z <br /> Ap�b•tMn A• <br /> n <br /> ►N or Grout btpsst m by 0•H Finns Inspection <br /> } <br /> Aedhionsl ConWMWM: t <br /> I <br /> AWl-csutt - Returs all W040 tot RAN JOAQUIN COUNT? PUBLIC NX,J,TN SnTICU <br /> E SHVIR01145NTAL NIGLTK DIVI51011 PXBIIt4/3XIIYIC1I3 <br /> NB N SAN JOAQUIN, P O BOX 2409, BTUCKTON, CA 95201 ! <br /> PEI t <br /> •PEI AM0I/NT Dv# AMOUNT AIMITTIO A N aICE1Vt0•v OATI /Saha• NO. ` <br /> $ .Itt ts1.rate r"sl t3� <br /> t ett•sae i <br />