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;. ,4"PLICATION FOR PRRkIT v11. <br /> 2 <br /> :��quiz Cot*tk tJIIL C HEALTH SERVICES ��W <br /> a ;$NVYINI�$NTAL HEALTH $IV4ISION <br /> O <br /> 445' P$ONIs (209,)4fi8=3420 <br /> '`T p O HOX 2008 i VOCKTON, CA 95201. ( T <br /> RSS Y R <br /> (Completd 'iti, Tr,iplicat <br /> .1lpplicawtiotY iii 7 q i <br /> A <br /> ii hbrt* stM46 i6 Sen ,foatiuin County far !► permit t6 t6hiitiact h'd/6:t; inrteli the %fork her'eia daotribed: Thio <br /> applie*tioti ii-hide ifi ctittplianc-a trtth ban Joaqutii County ordinidce Ho:.51+9 a o 1"2 and.the kulee and AegwAtione of San <br /> Joaquia C6ueiq Diene Health f3si-iriebil <br /> City �/ /� Lott 81>:e/Aci:eage <br /> r O+ivnir'i Name I_lei ii l[f- t3+�, "Aadreiii t 'n Fi[in' �' <br /> , <br /> e •# y <br /> ' •I , 7 .T Phifne 'fl <br /> Codliatt ." Addrbs>< License Nb. r <br /> x TYPE OF WELL/PUMP:,: NEW WELL ❑ W LL REPLACEMENT n DESTRUCTION ❑ Out of Service well 0 <br /> ilfvifs INSfiALLA710N ❑ 5v5ffiA REPAIR C]. OTHEfi.0. 1loiiitoring titeu C! <br /> OISfANCE TO IV�:AREST SEPTIC TAFIC - , SE1h1Eit LiiVES D15FiO5ALl t <br /> r i 10 PAOP. LINE I' <br /> FOUN6ATION i AGfiICULTUItf.=1+V E LL O*HEa WELL- PITS/SUMOS _ 1w` 1 <br /> IlVTEfVOEO U ES tYPE`Of WELL;. .006f3LEM AhEA �' t`DNSTf UCtION SPECIFICATIONS <br /> L-)Induitfrai 'O 004h 66tt6rh ❑ MAntaca Dta'of Well EiitAVahon Dia. of 1/yell Casirig y <br /> �Cl Doi'tti=tk:lPrivita 'S� 1 Cl,r;,rav2i peek _ � ,t O firsts . i' fype til Caiirnp� 5pecificatiorii _ �r <br /> 1'I hu6116 "y n Otlibl t f I D611 i t3epik';5f Grein Seai type of WOW +' <br /> ' I l lrripatior� ? Aootdi moh 1,I E4 orn ,;;$urfic Saul Insialledrby { <br /> liepair Work (36rid } (� tytiii 01 Pump H P F+ SWO Work Donb•� <br /> " L � Selling Ilat+nfial f. Depth II <br /> Well f whidtiisit f� Wall bi3rnritbr <br /> Depth r irillex�aiateril L paptb <br /> TYPE OF SEPTIC WORK NEW INSTALLATION <br /> REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system pprmitied it public sewer is <br /> .� ` avarl�le 'thin�f`��...� <br /> #i+rtsdLilort Wiq iarvi hesklanr Cor13rn1irCial - Other tT s � fi <br /> Nuni�it of Ikln iirriti: 'Number of bid►'ooinai `� r� <br /> r old F <br /> CharactN�#soil its i ilapih of 3 fibs. r `i; Water table depth <br /> ,D Typi/Mfg Capacity c! N6. Cornpatirmnti y <br /> PKC>I tflfFJ►tMEN hlT C7 5 .l „ ,sr N + '� i , r Me of Oisposi <br /> i° i istanca to iSl}llrait Vtlail 'i�ouiiddiid'ii��, proporty L►ri���� a- �' <br /> LEACHINd LINE L7 No. $ LenQtti of lines �+ total ianpth/8i:a <br /> I� <br /> FILTER SE3 CI faiatiircll#onbafiit Well Ftwndtioitf.', ;. _ Property Line <br /> 4 r <br /> �1. <br /> SEtcf'Adg PIPS, s 1 1 660th 6t Site , c ,,` Number,:.: <br /> SUMPS r, '�i Drhance to a:t Well i~ottndtition Property Lrna <br /> DISPOSAL 00kb l „. CI <br /> N . : 6 j L � .d <br /> 1 hsraby Corti that 1 hive priparb6 thio a., iters and th6t`the woik Vrih bis.donr in uccordanea with San Joaquin county ordinances, state lows, and <br /> rulas and roouletrb`nt bf ttii Stirs Joaquin 0 <br /> Horne oV�inir of licaniiad 1i n1 s iiipnittfrr3 i3srtif 44(6hdWln6 I t;tttrfy that in th8 p6ftrmanca of the work for which this permit is issued, I shall net <br /> employ my piit h 16 Mich 6jinner ai to bi cotrii iubpct i6 Wbrkrriah'T tomptii%"ibh l w!of Cakfornia.''Obntrectot`i biting or sub•coritracting signature <br /> ' certifi"thi f6" "I"rtify lhaf in the p i driiriltitli of the work for which thio pirrriit ii isiusd, I shbil imploy persons subject to workMOMI'compinia- j <br /> tion Ia1iYa o y -, • r., ,E, rr • s s. , r - - <br /> T SIM ' call f .r '" C Complete drawing on r rse side: {; <br /> t;ignbd Title: 1 Doti; <br /> I`bq DEPAiI1tMENT 118E ONLY #4 <br /> Appliei66h AcCtiptid by 2jt e `-{ 17iftb Area ! <br /> i 7f <br /> PN a Gr6tet fnspaetbn by - oath Final InipbcV,6n by Date �� l+�r Z <br /> 'Addltlorul Comrnints: <br /> o,,S ' <br /> Applicant Itetur5 illi 'eopieii to + had Joaquin Coiinty'public itea2th 3e#"viae$ t(� °' rr: x <br /> KA <br /> 13isvironmental'ttealtti Pr�rtnit/Services ( Q�e /Qfa7'o'f <br /> 446 H San :loaquint P 0 Hoar 2009i :Stkri; aA 9626 ;1711.; <br /> INF AARtRiNT but AMOUf�Mrt[tEMITtED- CASH , AECCK EIVEp by DATE,; T' I <br /> 4 EH U-24INEV.4tA$I <br />