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4 ' <br /> ! p' <br /> L <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SF'RVICBS A 4. <br /> ENVIRONKENTAL HEALTH DIVISION ` <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 ' <br /> PEMI�PIRES 1 YEAR <br /> (Complete in Triplicate) <br /> AnLicatldy Is hereby sndR.to Ban Joaquin County for a permit to construct nn4/0r tost&U the rort herein deserlbed. This <br /> 4TIleatlon is aside in coWltance rith Swa Joaquin County Ordinance Ho. 540 and 1862 and the fAtiaa sad 110CUlations of Ban 7 <br /> Jpsquiw CountyPublicHealth Seraw1ces.{� {,� Q� �!� C <br /> Job Addrm G� • �� �CN 1`�------ CAv--A) Wt Size/Acreage <br /> M� Q4l�tWt~'�..Add,.. �� phone 2? . . <br /> Ownar'e Name Q <br /> /so TR1A1 I�Crcen4!iio, -'V3 "one 2-3 <br /> AdaireT! ----- <br /> �8 ie <br /> a Cm+dultr <br /> r AS <br /> TYPE OF WELLIPUMP, NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION L1 Out of service v#4=1 'd <br /> i, Monitoring Well 0 a <br />,I PUMP INSTALLATION C3 SYSTEM REPAIR 0 OTHER ❑ f <br /> r` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FiD. PROP.LINE <br /> t r FOUNDATION'^ AGRICULTURE WELL OTHER WELL _ PITSISUMPS <br /> ' INTENDED USE TYPE Of WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS ,f's <br /> n iwustrw ❑DPM+Bottom ❑Manteca ^;e of Wan Encavt'ioft Ow. of WN Casino a. <br /> i t Donntre/private n Gravel Paet7 q Tfaey Type of CefmO_. SpiseiFeatroM W fgc <br /> Il Piibec I-S 09W n Delta Death of Grout Sisal Type of Gtout..., 'tF <br /> I I Ingeton Appro:r, Depth I I Esstwn Surface Seel Installed by .; <br /> Repay Wont Dons L] Type of Pump H.P. State Wort Dons_ <br /> Well Disatnrctiort C] Wen Diametw <br /> Bawling Material 6 Depth <br /> Depth T111ar IMterial Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION OEyTRUCTION I I INa sapec syatam POP rft I! If pu660 sewer is <br /> r/ within 200 feal.l <br /> fnstallation wile sere: Residence ✓ Comwwclal Other, <br /> Number of wino,n+ita:_L— Numbw' bedrpa <br /> GTwacm of W4 to a depth of 3%st: .y <br /> \ Wetwt taye J <br /> ^" <br /> TANK C] T lfrH Caped 1 IVo.Contpwtlmafns i3° t <br /> SEPTIC A Yoe p ., <br /> PKO.TREATMENT PLT,a Meted of Dkpod ' <br /> Distance to 440 as Wen Fwndalion PropMty lin♦tdsoL ' t <br /> LEACHING LINE CI.No.8 Length of limes jowl Nngtlnhin <br /> FILTER BED n Diatanar to noarea. Wdl V fcurkdation Property Una <br /> A <br /> a 'moi- <br /> SEEPAGE PITS I I Depth Sin -.— Number <br /> SUMPS LI Distenoe W rt08 8 W.kri..._ Foundali�%n PMWAY Lima <br /> DISPOSAL PONDS ❑ <br /> 1 that I him prepared this aoptiGatbn ar,d 1hN the wet win to done in a.^eordants with San J0aquAt COUMy 011`411 eeb,stow laws.OW <br /> rules end regulations of the Son Josquin OotttN,y . <br /> Mofna owrMf a QcisnMd apisnra aipnaturs anMiee tM faeo+aetq: I car"that in the parlW+rgMnCa of fM wort for rNrkh this ON IV M leetred.1 ehM not' <br /> any pwraafn in Such mMner as 10 become vublect to—%~'e c0fir" OOn I"s of f allatnla."Cafq+aetere h1'EnQ Or ati�peeMraClh,q adOrtatttrs t <br /> ampwY to wattman's Campo"*-. <br /> urtNies the fpaotfM,p:"1 osrttly the!in Ifte o1 Stns wort for which this pewit le Isom.1 ohaq Mtapbr Psnolw etrbface <br /> Stan hwa of Califlarnle." <br /> CompMe drawing <br /> The aPp�erM �o!M en rwe*w side. <br /> Dar.: <br /> . - FOR DEPARTMENT UBR ONLY <br /> AppNewtien Accepted by _ ' .r so.� - ���J,., i <br /> PR of OPout IIMpo~by Data Fina InspeCtlen by Data �Iro% <br /> N <br /> iy , <br /> Agplieaet - Rrturn all copies t Ban Joegats CcHaY Public Healt Berisleee <br /> gerlroewnaal Health f>wrnit/8errltea <br /> 4411 M Baa Jo.T'sin. P O Run 1M119, Sth" VA 911201 <br /> ME <br /> Fit AMOu T OUa AMOUNT aimirTEo I gtCElyib BY ATE <br /> Nor <br /> Joel <br /> .I«,s>.tan►.�..., !1 ,r���'- <br /> eyes.„ <br /> � 1 <br />