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APPLICATION FOR PEMIT <br /> SAM JOAQUIN COUNTY PUBLIC HEALTH SBRVICHS O (� <br /> # ENV2RONmEjgTAL HEALTH DIVISION <br /> 1601 E. HAZSI.TON AVE.. PHONE (209)468-5420 "��✓✓ <br /> .� . P O BOX 2009, STOCETONr CA 95201 j, :Mj; Zt��33�2�01 i <br /> 4 E ` <br /> -,�c'� (Complete in Triplicate)` <br /> rlppliCatlaLt 7e brrrtrT ee4e w 5 :farvle C4 ry,T pete:t+to eorn..rwt rIar Sttstmd ttra Rule* and ptRttlrtLtaos of 8at1` <br /> -; Amlleatiod SSI Bade in cowlialsce .its 9a4:ottgt1ln caciasr Ora.not+ee 9 Qggw070-fl4'�BS <br /> L dcwEuln Coudty Fubuc Realtb 8rrTLees. I E (�O APN <br /> Jab A"rmmmn <br /> NarM t✓rri dddmss �5�1J7k' � JLG.^""Ph6t+t f c <br /> ' Owttw f _ w... <br /> . .COMrat! _ AJ'3rrS1 e—t__-_m��r-E„rv.�i4liCl.'Se NO.�i.to-A �' <br /> TYPE OF 1IYLLLfPU?AP- HEW WELL ❑ WEL' :EPLf•LEVENT C., DESTRUCTION L7 Out-Of Ser+ice Meij .11 . <br /> PLW-v INSTALLATION C :Yli`sm REPAIR Zj J7kEi#`fR,TS'SI" ^6 <br /> _ DISPOSAL FLO. J <br /> DISTANCETl HtARtST: SEPTIC TANK 5£NcR LvES <br /> # <br /> ,. <br /> FOUNDATION AGRICULTU'?£'.yELL OTHER WELL +�-�-^-•� f�� <br /> INTENDED USE TYPE DF WELL OROBLCM ARCA C_6yFtRUt7tDN SPEttFICATIONS <br /> Yx <br /> t.i It►l,rstrur � i:]Open Bottom C;'Mrn:rce__ i>.a cF wed E:carat sn -- -- eS <br /> T-1 Dorrrsst+crikivNe C+Df"Pock n Tracy Lyne <br /> I7 Other <br /> I Dere +gym of Grove Sr al <br /> tltPa.nf <br /> IA INA" �► ar xp'�i: <br /> r,ingatrpn �,Approa,Oepth 1;Eaatem Swfece Ser$Insuusd by , <br /> • H P ,.,�..:.�:.. State W" Done, � <br /> new won Done L7 Typa 41 Pump <br /> WA Destruem t C Woo D�www __-- Sealitts material.i e - _ • , <br /> Meurlal i Depth <br /> Tiller ptb <br /> TYPE Of-SEPTIC WORtS: NEW INSTALLATION 1 f REPAIRrADOITION i i DLSiRUCTION I t $NO 00010 system 111"Mied A Pnbat ewer is <br /> w"Nn 200 fow.1 <br /> Ify:tlwltlbtl writ eaM: Residenp....._ C4�+nrttlM_� Olrw_.,._--...._._ <br /> „ Wernber of bedrooms <br /> NuntUer OI frw+p Urtr'e:_ <br /> Water table drpth` <br /> I Chwector of w ft.•dwh of 7 het: <br /> ' tewcity No.C4mpanttlenta •.ter „ <br /> I SEPTIC TANK fJ TypelMlpUoob*d of Odom 0 <br /> a <br /> MG.TREATMENT PLT.O <br /> D%ssarice to newest: Wet __ Foundation Property Late- <br /> sl :+tgtfifsitt•- <br /> lEAClilfdG UNE CI No.i Length 41 knew Totti <br /> FILTER BED 0 Distarw <br /> nce to ten: WadFdr dawn 11 P.""file---� <br /> SEEPAGE PITS. 1 1 Depth —Si". Number <br /> SUMPS LI Done"to newest: wen Fountiar on PrOPWIV Line <br /> �? DISPOSAL PONDS ❑ Ta <br /> _ t"Way tJaRAy that 1 how*Wepared thin apOErtrirOn and that Ow ware wA be done in aCCo+darrce Witt,Sart J*MprFn countY otdon tams,sTan hwo.and <br /> pries and NeAstem of etre San ro"tyor . <br /> Mohr owtlw :Sio Id"epam's&"two cores as the toNawr+p:'T Ce*n'tY that in tyre partwmancelo!the r.ork foe which Inti` i>�L>r iswMd.( rwnor <br /> " <br /> " employ W V person.n s:rdt MP~40%w bwor+o subteCt to woebawn's coff*wr"at�on taws of CA for tantraCtOra tritit�or eual otttrsetirtp dgnstwe <br /> tarhlies ow IOiCA+q: I cemh that an tfio perlomav CO of she wwl,for whKh thb "now is Issued.1`ah" now Pormw rdbioct to workmrt s componsaa i} <br /> f <br /> tion laws Of CWongo.- <br /> Teta eppicant Cal for at1 inspretiar s.Comptes+d•awint;vt reverse side. <br /> -1a Date' <br /> � _.;. <br /> Sa <br /> - <br /> - FOR DEFARTMEFIT USE ONLY - xi <br /> Data <br /> rt App�ption Acppsad by <br /> Date Fiat Ins�r.c6aft by � OJly <br /> ek a Grout Inspection by �..��-- <br /> t Additional Curl rr: <br /> ` Ayplteant Return an copies to: Sar.voequla County Atbllc Healtb <br /> Serrlces, Zw1ramental 8ralth perrlt/Ser+icrs <br /> 1601 E. Iiateltod Ave— P O BOX 2009. Stock:oo. CA 95201 <br /> "FE£ u,epEly-DUE' AM"ttT R[WrTED cA rt RECEIVED 6Y DATE <br /> I*ev •s+ 4 SS <br /> �t-'• �: s�y� p o—�oQ is <br /> Xl <br /> _ R„ ever , , - �;;.. .e,".;i ..-'�t[� 1...�f�" °� �±h s•_ <br /> i <br /> �,.r <br />