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�I JOAQUIN COUNTY PUGLiC M-,,U.7111 KH:E1, _.:ES S
<br /> 1-.Nv!R0NMU4TAL HEALT11 DIVISION
<br /> '.I_`) N' SAN JOAQU1, 3a1EONE 1:'-Q�1•Ifi 1S_ 34:1
<br /> P O 13OX 2000, 5TOCKTON• CA 'ir)l01
<br /> Pk:HMl'F' 1•:XI?1RE•:5 1 i1�.�H wl++)M I)AT>_l�i:>U�E)
<br /> Application Ta tart~ s ar to
<br /> ,.n., ,. tc ..�•.) ^i c.. ..' •n: , .. 4,••art-e.., i
<br /> appltcation is gild- •
<br /> Ir r:•ry.::en•: ..,.r;;wr. ..r�s•, .. s• s.. x wn. .r•r,:nl..,-
<br /> ,DaquiA Cosnty Public Health Servlcra-'
<br /> Job Address
<br /> ���..�_'_'}t1 '1 F4� r•-ss , `z '� �Y �.'•.s�..�,-� '�w.,-_ __ Pm^•'e _.-J-__-_..__ -�._j
<br /> t i�•rtI .i�eT P! _ is_: 5 7 j. .fl: -1ri�L _. _ _rYrnnP._fir�12`��__;J-i .
<br /> CBr:I'aL lir _..-t°
<br /> '-- -- NY• L�[. � •7L: Fli, if :pil_TI(7'ti Chit e' :er'1rlCr ilei
<br /> TYPE OF :^lEi.L,PUHIP NE :EL
<br /> ----'--- P {Fi O' lER _. Y.on7 tering Wel.. C.
<br /> yUf:PINSTALLATI(:H �- S'rS'i..*-.E .. '
<br /> PLC)
<br /> . 0
<br /> f
<br /> `�
<br /> DISTANCE TO .F4RF5T: SEPTIC TANK SEv:EP! S .� PROP r
<br /> FOUNDATION AGRICULTUPE x%eLL PITS,'SUMPS _
<br /> .
<br /> WTEtiDED USE TYPE OF WELL PROBLf tie AHF A CO'+ST.at -T'O_:SPEGF-CATFONS_ i -
<br /> i i Indust::a, ----. r.-'.Open Bottom f;rianfec# D•i of LVnh E•cavabon -- Da. at Well Casing {�
<br /> c!t; s •. ?t?` 1 Stxc•lrcatwns
<br /> �Domesrc Pavane i Gaye,oath .Tracy ':✓e - -
<br /> i'I Puhtic ' Dlhar • Dc':a Dentn c!Grout Srar '_.t.L k_I-_._. Type of GrovF �' _.
<br /> F I Inge uvr. CLL ApMee Dep,h `1 Editarn 5urf?ace Saa1 tns;auad by
<br /> Reosir VJurk Oo,,e i_' Type of Pump jJ1a1— ra P-__. 7—_--.____-_. Sive t':a'k Doe.e - L�
<br /> Well bastru[tror- i; Well 6rame!er
<br /> Sealing :aw:erlal l
<br /> Depth ^-- -- Ftller Mater"Al i ;,•tth _ -
<br /> TYPE OF SEPTIC WORK, NLW-INSTALLATIO`+I! ;IEPAFR-ADDt T;0-N GESTRLICTIC)N t'.a sepr,c srarem permuted rr puD:d sower•s (`,
<br /> Ara.ldbid wrlllrn 200 feet.)
<br /> Installation will+,n•e Rasrdence_ ComrnerGdl Other�• _ -
<br /> Nvmnar o1 king units:.... Ncmbee of bnC'oom:
<br /> Cha,acter of soil to a depth of 3 feet: Waler tibia depth f
<br /> _ SEPTIC TANK O Ty"/Mlg Na.ComDertr•+enU _
<br /> PKG.TREATMENT PLT,LT Method of D•soos37
<br /> Distance to neerrst: well Foundetion___—_- Piopeny Ldne
<br /> LEACi-(ING LINE 0 Ne.d Length 01'+ es Total:ecg:n.rsize
<br /> FILTER BEO Cl Distance to nearest. Lvelf _ Foundation- NofWnv Line
<br /> SEEPAGE PITS I I Depltr Srre --- Numanr
<br /> SUMPS LI Distance to nearest: well-- Foundation ._ Prdpenr Line {�
<br /> DISPOSAL PONDS
<br /> I hereby certify that i here prepared 1h,s application and that the wOlr will Ce ao••a in accnrddnce wren San Joaquin county oid.nances,state fart's.and
<br /> rules and regulations of tho'San Joagvin Conn Cy
<br /> Ho-no owner ar licensed agent's signature certifies the Iolaw,ng' "I Certs,I.ha:in:he txrlo,mance of the work fur wh,Ch I7sS:,ermn Is issued,7 shall not
<br /> efnploy any persor.rn such manner as to become sub}eel ca wvh man"s compensation lao.s of Celdorn.a"CnntfaVor's hiring or sub is
<br /> wgnalwe
<br /> cerydies the fofio..virg:"I certify that in the pnrloimance of the won,ler wh,ch this paerc:'7 Asuea,I small sniplov pdrsor.s subiecr to workman's compens3-
<br /> tion Saws of Cahrcrrpa__.,
<br /> The applicant tY.Lat can lair all rrgWeed inspections, Camorete drawing reverse s•de.
<br /> Srgr,ed X1 t — = v "�`% Dale:
<br /> r
<br /> FOR DEPARTMENT-USE ONLY
<br /> Appheoison Accepted by _- -_ _ Oate 7 Aria
<br /> PA or.Lroutlinspection by 1-7111 7 11Yi.�u.0 Oa,e Fmsl inapnclion Qt'
<br /> Addrtionet Coma nts' .t! ,I ��;,.,•L- - -r -�_ ==� .
<br /> - Apel lr:nnt - 1!r torn n7[ cnnlr•a rn: tian -IonyulY t'nt.o rt' P._'.11.. !1••slih ..:.rr f,.,.: :�'M1.
<br /> !tori rnnmtnlxl L• •h p .�l+• .:I• '"1 //J�A�n/ � __
<br /> 4.15 t< S.. .F.]:c.l.rlrs[. t���fr-F-— - rx 'A--•S:Si,I
<br /> `NEO AMOUN DUF Ar.+OUr♦T nEMI'�ED - e NE[F+.'`D 9t' ATE aFRM,7✓NO
<br /> '777 ) t
<br /> FH la7e /�
<br />
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