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APPLICATION ENU1 ' <br /> SAN JOAQUIN COUNTY PUBLICVIC ' I ENVIRONMENTAL HSAI,TH D Villa <br /> 445 N SAN JOAQUIN, PHONE i OQ] k3420�D 4�+ ---- <br /> P O BOX 2009, ST+DC" , (�rA'' ' > <br /> PEMIT EXPIRES 1 YE" FROM <br /> (Complete in Tripli 1w# V 6 e7 7 <br /> Application, is eeraby bade to San Josqule County for a perste to cowtrue[ La <br /> application is aaAe iP etepliance rltb San Joaquin County Cr,l"sree No. 5bg and 1862 arta the R}Une Mrd MNulatiope of San <br /> Joaquin County Public Sebllth Services. / s <br /> Job Adoraaa }G' t7 �4. I�.Q v� iiiC3 �ltl.� �-1 1 CRY ''`/L t Lro�t sl3e/AcraaB!(A�:il.(;.-Y�( . <br /> ✓Otwtei•NanM;x'tc lY la�1 �..ZL'1 t)1 Address � `r�'+L 7 A' /)u L ,Lt Lit /t-� Phme -�r�J� <br /> Address Dpnl`atl '� C • <br /> . a'M`+[> /' G�, �LY. �61 'U`",, yM�fN �Ln Zz-4 P1oM SGJ S IL TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT CI - DESTRUCTION U flatfryiwe1IPUMP INSTALLATION C SYSTEM REPAIR C OTHER C Novi tcrryYell <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE$ DISPOSAL FLD.__. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL -_ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Irwuatnal C Opbn Bpnom O Mantata Dia. of Well ElcovaTim �- Ola. of Wait Casing <br /> TI Oonexle,p iwu ❑ Gnwl Put O Tlaty Type of rssinp_ SpeoNlcalons <br /> C. Pubhc 1.1 Otlw F1 alta Depth of Gwm Seal - Type d CNout <br /> In"wn —AM04 Depth 1 I Eaelarn Sud",Seal mile% o by <br /> A".,Wore Don ❑ Type of Pump N.P. Sten Work Done )13_ <br /> Wall Dosuuclon C Wall Oismenr sestln6 Betwrlal a Depth (N <br /> Depth - _ lorial A napth <br /> i VPF OF SEPTIC WORK: NEW INSTALtA TION gEPA1RMD0_ IOW DESTRUCTION INo taplK sprem permnre,t�I amkt wwor Is <br /> avadeow wdhln 200 loot) <br /> thetN4tion we serve: Flowdenm Corftmarcief_ Other <br /> N.m of shag urine: 1 N::!7 of OenM_- <br /> Cluvactp of eo1 to•dpth of IoM: �Ly - "1C+C,,. Wetar taoN depth <br /> SEPTIC TANK Type/Mip / Capuiry�/L t. No. Canpamrml <br /> PKU. TREATMENT PLT.0 / / Method of DApoaal <br /> Dislanoe t0 MNeet Well t t FpuldaDon 16 f Property Lily S t <br /> ! I <br /> LEACHING LINE No. b Length pl linea /'- Tont W N(hyelal I ,T' h <br /> FILTER BED nOw.tp...1 What _5�4. Fouth n J_ Property Laos 'f <br /> SEEPAGE PETS It Depth _{'_—Sita .-Q X/,aNumber_ � �, G <br /> SUMPS � Dh, in Rust Wan_Acyy r/Foundstlon le + P,ap Laos,�f <br /> DISPOSAL PONDS O <br /> I hereby coniN met 1 Nava Wowed rho ePPkicMron and Ihet the web will oe done in accordance with Sen Joaquin county oldeunce3,sun Is.n,and <br /> .ales and r ebony of tM San J sq..n County . <br /> 1 fqM cevne M IKMtaad apant'a YpllPtun menfip the 101bMnnp:"I Certdy Met In IM pe"ohnn tca of the Wolk Py v hkh of$o"u"it to HYAd,I"no <br /> MMWY arty mnM in such~~ae to boxcl stob scl to workman's rompenxaucn neva of Cabfomia.'-Convector,nlutp a sub mmractitV a1Brlatuw <br /> mnlhea the foeovi," "t teDfy tfq o the peAormance of the v 1,for which this mrmlt is isMnd,I shall employ Panonn subitct u wnAmen'e oolllpsrlu- <br /> ion totes of Csafonil <br /> The apdcant moatIts GI MR. o •. Cornplau drawing on nverea ode/ (/�, �/Y <br /> S.gw. 1-Lf.Li C. Tit.: �y / 9p note. <br /> IS `-r r <br /> FQA DEPARTMENT USE ONLY -6 DO)Sg <br /> Appliastbn Acupled by ZrIC4<at Data Arts <br /> Ph W Onut Insmconn by Data Final[Mow.nn by Data �2 <br /> Adelllbryl Conevenu: t1 <br /> AG <br /> Applicant - Return all copies to: Nan Juaqutn County Public Health Nervines .^ <br /> �rrLIfnvlropayntal� Health Perel t/Seraleec ^� _/%Li/cv an N San Joaquin, P 0 Boa 2009, Stan, CA 9.8201 ,/t//.L / ��j,,.,•p/.�� <br /> IMiO AMWNT DUE AMOUNT REMITTED 'KNVEU eY DATf PERMIT'No. <br /> CASH ,-Ij/F"t(f 1�3 fQ4 <br /> .tH Asiantv.,,,u Q ` e.('. 9 1l 3�1�3 r 6' <br /> EN us <br />