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1� <br /> =3° APPLICATION 4CA <br /> SAN JOAQUIN COUNTY PUHS&ENVIRONMENTAL HEQ�'{445 N SAN .IOAWUIN, PH68+[P O BOX 2009, ST005p0}, uYKAR <br /> PERMIT EXPIRES 1 , SSABD(Complete in T � �FAmlicatlte is hereby ride to Ban Jatquin County for a pe,otit to eor /nsu11 the work herein descr a <br /> '"Lleatfan 1a tale Sa cowlltnce wtth Bao Joaquin County 0.dIcsuc• No. 519 and IN? and the Baca ant Re iiiatione or owi.r <br /> Jeaquin County Ntt L'c Health Cervices, <br /> Jon Address 23361 N DPVrins Nd- Cl,�rvra�� _ Lot BS re/Arres41 <br /> Dane,'{Nama PIa Dt]nLj?-j-rnn _ Ac•A:es! .same PITCHi <br /> Contuclm Mot ton 9e tIC. Addmss_ *{T Q r Icenst Na.4469,25 Phone <br /> TYP F WELL/PUMP NEW WELL El --WELL REPLACEMENT 11 DESTRUCTION 5 Wt or ser ion Ye13 CI <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C OTHER G Monitoriry Yell 0 <br /> D ETD NEAREST: SEPTIC TANK SEWER LINES —_ DISPOSAL FLO.__ P — <br /> ION AGRICULTURE WELL ___ OT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL CON N SPECIFICATIONS <br /> Indwrinal 0 Oosn Bottum 0 Msmeca D'a kcav{Ibn O's of Walt Casn <br /> DprtN•bG/Pnvns Ci GravN Pack V iYpe of Cuina_ gNT <br /> $psckica <br /> Pubut Il o"ntr n DNs OWIT,of Gout Stall TIP"o1 p� ` <br /> Irr J•11rn o. Oeplh 1 1 t Ten $4rlxe SaW InPaMd by__ la1a�� N <br /> 0.epTl Woh pens Tytat of Pump H.P. ,�_ Stats Wwk Dma_ JT LAI <br /> Wall OPTIC ton 0 Wek Dianalet Be{CioA Material A Deyth tem_ AQUI Ni <br /> Death _ Tiller Material 1 Drptn EALTH SERVICES ECT <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION IX REPAIRIADDITION I DESTRUCTION( I (NO tePIK ,(&R fliJP ebac Inas#a <br /> awdaMe wnnin 200 1., 1 <br /> InalaEFlIn11 w:h MM NE{40nCe_Z Cammncwl <br /> N.Nnbet of wars w -W Number of bad,eoma <br /> C"mcce,M wk To s dplh o1 1 Ias,. Anna Wale,IeWe depth <br /> SEPTIC TANK 2 Typt/Mia .L`nCrR ej-_p&-jCaW.,ty T 2nn RAT. No. Cpmoartmsnu C <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Ofriance,to covert WeV I rn' Foundetan'.'__ PropsnY Line <br /> LEACMING LINE V No. A U V',h U tine% 3=_LI1Il!13.I1e8— TWN enalh1wi ' t') <br /> FILTER BED 0 Daisma to nasmitt wall 1'i0' Toundstwn T R, _ ProWrly Line <br /> SEEPAGE PRS I I Depth ___Sin Numbm d <br /> SUMPS LI DM11nCa to Deems, WO__ Faundeuon P,opnty Lir: <br /> DISPOSAL PONDS 0 <br /> hTaby wify IN.,I rrw prtoartd,hk VOIK Hron and,ea,;M walk wN benoro in ncc.danp with San Jo '.Co.."anphsncts.Tarr Ia. and <br /> 'ulss Thi raaulaliant 0"M San Joeo�- C.cy <br /> Horre,pxmer cI 4tr1M1 ".1 IT 4analVe comfew IM 1.d Q."1 CNify IMt in think wiwmant,of IM work To,tMKh ihu fxvTl is iouied,I"it no, <br /> tmplev env draon in•wen menu.u to neeoma tu0pet to workman'• this <br /> Own ss Cd.I sh,1." pay Patent hinny or ao wort•"1,c apwo <br /> caniba Iowvn :"I cion nw N the Wrlo anti d tM work far aM'cn this portil L iulrtd,1 anek smpoY errors aubjtm to woramen't tomlasnU- <br /> Ibr. Til C I'6n ' <br /> The can" t r WI,p and» dein diswna ix,'"re,aide. <br /> Siaryd - tgtr contractor Debt- 6-70—Q4 <br /> FOR DEPARTMENT UBE ONLY Lf <br /> Appkcstbn Acctpvvd by —_ _ Dot. <br /> Ph It,Gfawl Ineolvid.BY Grit F.0 ihamcuon by Dom L $2 y <br /> AaditgnM cor,tn.mc <br /> ApPllcont - Return all topica to: Btu Joaquin CnentY Public Health ServleenMImle /J �, / I <br /> LPviroSon tai ulji, Pe Box 2009, Sikh. <br /> SNOOD 37/O <br /> 445 H Sea Jawquln, 0 Box 2008, 8tkn, OA 09201 <br /> IMEO AMOUNT DUE AMOUHY AEMtITEp ABNCIFH� PECeVEO by DATE PEAMR 40. <br /> 'Hum vele H4- I (� V O <br /> I <br />