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x. <br /> 41 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-5420 <br /> P 0 BOX 2009, STOCLTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE_L-&= <br /> (Complete in Triplicate) <br /> A011MUM It Mab WAO,M Sea Joatuto County tw a p.rWt W ease t and/or Lnst&U the work Mt'ala"tttibed. Ealy <br /> SM11"t1a 16 tW fa eRftll.nrt with W Joepofa County Ordimaet So. $ig ad 156E W ties NWa9 OM MEaletie at hN <br /> Jewde owmaks r"Lle Sa1N Mrrletn. �s <br /> Jet,AAhes, a:Z&j LC U :Fly 15 " -, ClY!53 tai wt Nie/Ae�� <br /> Ow aw's Nang AA�A..ttj <br /> ( <br /> Ufmte <br /> TYPE OF WEl PUMP" NEW WELL U WELL REPLACEMENT CO DESTRUCTION O Ott a WOU L1 <br /> NMF INSTALLATION O SYSTEM REPAIR Cl OTHER O NMltat's"S Iwi O <br /> DISTANCE TO NEAREST: SEPTIC TANK __ SEWER LINES DISPOSAL FLO._ MOI.LNEI <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL MTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n uwww W O OPan Son" 0 Momtcs Dia.of WN Eec www, DOR.of Wal Caeay <br /> (l DornwlM/Hutu ❑Gravel PscY ❑Trey Typa a Cawq_. SORaReRMRnR <br /> I hrMe FO Oewr fl Delta Depth of Gran Sea fres Of Grove <br /> .— <br /> I I IMP w r Appel. Depth I I Easttm Surface SM Ntalete try <br /> RepM Wort Dom L1 Type of Pump M.I. Suet Welt Dam_ <br /> WON DMFuction O WEB Di _ Sealing Material a Depth <br /> Depth F711.r Notarial R Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I Igo e9plx:aYelan pawNue M put,OC ester M <br /> availst,M vwlNn 100 I <br /> IrrisaWan tva ww: <br /> 14aaa9ma_ ColnmatW A Other <br /> Numha of"WINE:_ Nun*w of t,Raeo, I <br /> CMwaa o1 OM w a depot,of E Ma• _ WRta IMM Alpvh <br /> SEPTIC TANK~W-0 [agent,_ No.cathpRnwrMa <br /> PKa.TREATMENT PLT.O ����ylr���� yMethod of Dlgt)ael <br /> Dlslance to ruefwt: W /Zy-_ Fourdstbrt /t57' Prop"Lim r <br /> i <br /> LEACHING LINE No.S LargM of firms A=Zr r—' // Toni W.Oh/an Z <br /> FILTER BED Cl Distance to nwM: WM .Found~ Property Lim <br /> SEEPAGE PITSDepth �_� Siw NMnDa <br /> SUMPS 11 Diwanca to nearest: We Feumarron Properly Lau <br /> DISPOSAL PONDS 0 <br /> n I h ob. varte,that I lova pepaeA I"appaeat.6rt anA that the vrorh uviol M dom vi eeerda ce w h San Joaquin COW"aetnanC m qua Mow.am <br /> a <br /> rule stuP <br /> upAeel Asp SM."turn CelaCountyHerm CwW er Oat rad spew"',s,aston w the foto <br /> s warp: "I 'a that N 1M pMo menta v 1M were ct which 11,41p9rrrtl 4 I C I 1 thM net <br /> enVaty <br /> uboc:v to <br /> laws of <br /> taptattre <br /> 3 eRrlllMe the Mbwatp:"I certify that innttm p11rlomance of the v otk a whilh this Parmit is iewrW,1 ehM S-Voy pawts KA10"to rMm w,'6 co 1pwR- <br /> lion ItM of CaMpNa." <br /> ThepppeaM el t Mr OR n�q�r �]x�w�etb».C.w.etwa aawnp a m 11.69. <br /> la <br /> guyOL�/0 . r - ' TSM: 1 Deft: <br /> IIIVV�IV lfpR PARTM NT USE ONLY 'Y <br /> APpk~AcCpteA Ory ai - TFC�hmaaaDate <br /> PN ordeal anpetlon by Dela I"Impeder,by <br /> AelUonal Car,ertana: <br /> Applle.nt - Reture all 0.0100 to: Ree Joaeula County Pogue Nealth eeran.. I <br /> ReH ro.wn tel malth P.rwit/genie" <br /> HP h Ban JOAeule, P O Box EOOP, Stan, CA P5201 <br /> I{[r'pittt AMOUNT N1 AMOUNT REMITTED A N RECtNED BY DATE /jPlah rt no. E <br /> . tw 1st,Dery ..trl l/-- // Gary , <br /> EM tela YYY <br />