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APPLICATION
<br /> Sbe'JOAQUIN COUNTY PUBLIC HEALTH SORVftIS
<br /> ENVIRONMENTAL REALTH DIVISION
<br /> 445 N SAN JOAQUIN, PHONE (209)488-3420
<br /> P U 13OX 2009, STOCITON, CA 95201
<br /> PERMIT F.]@IRBS 1 YEAR FROM 17A'l'E I39UED - ,
<br /> (Complete in Trlplicalt+)
<br /> Applleatlw to Mnlr, lade to Swe Joaaule Count, for . peralt to eon.truet .,!d/or Install the cora herein described. this +
<br /> APPlleattw 11 seats 1P ec;lime* at" Ihn Joaquin Court, Ordlnsnee No. Sep one 1362 End the Rules and Regulations of San
<br /> Joa0.1e County Public(Health Services.
<br /> Job AdAnM if u 5�IyA,F•_l�—__.._ Cary/ Lot :11fr/AerryP
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<br /> Ownols Name '� �+ Addicts ,. tL, L4.[��� Phone
<br /> C set,off, .Aad,efa1,�
<br /> Lkeme Nuv_P_'3Mfj=-Phone
<br /> TYPE Of WELL/PUMP. NEW WELL D WELL REPLACEMENT n DESTRUCTION Ll Out of service Veil 0 (i
<br /> PUMP INSTALLATION C SYSTEM REPAIR C OTHER D 1Ynitertrq well D ST
<br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _.___ DISPOSAL FLD._ PROP. LINE n
<br /> t' FOUNDATION AGRICULTURE WELL OTILER WELL MTS/SUMPS
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v
<br /> D hausu.0 O open sones, 0 Manncs Oaf. of Woa Efuv.,on OIs.Ot We[Caslnt
<br /> EI Dorrrfde/PtNah 0 Gni.*Peek D risco Type of Cednp_-_ SosedleMbm `
<br /> gOYc J,Other Il Delta t' Depth of Gran Sul Tape M Grout \
<br /> I I Inyahen Appel,Depth I I EMIrn S.doce Sell IMMIYd Cy ,
<br /> . , Repair Work Dorn 9 C � Tet*of Pump M.P. � •' 'Ston Work Done v
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<br /> Was Defpuetkn -D Was Dhs,saf Suallnt Material a Depth p
<br /> •Do.," • .. : Filler as r.tfl b Dopth:,
<br /> j�jj1 '.TYPE Of SEPTIC vXRK:. N'.W INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION 1 I IN."Pare system Pnmhled d pr0ic r.wras
<br /> - L ovsMDh vetNn 700 fee.1
<br /> t Lltl•RFderi wtT.MW: ,Reai1f110e G' E.pMMrLIM�"I�INar ,j
<br /> tAwnber d Ewp uwli:� .NIRMsr W bebooms'_
<br /> Chracir W wE b•Upth of l het: ty rQ2fvyll• Wstw nom deph
<br /> k - SEPTIC TANK'" 1I TYy/Hep ` S Capacity No.CarupnPsna ,
<br /> i PKG.TREATMENT KT.0 '�' •M Method of dpeW r
<br /> 0;a to.Wert WN Founders.. Property Line .1.
<br /> Q( .LEACHING LINE No.1 LoNth of h,.. /— larJ r Tout Ynptn/fYe
<br /> FILTER UD r3TD'unnce to russet. WNw.wal�
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<br /> SEEPAGE MS I I Depth Sw N.mbr Y
<br /> SUMPS Lt Oetrtu W r t: WY FeunEetkn heperty Lbs I ',
<br /> DISPCSAL PONDS.. D
<br /> IPa,faY taint'Mat I Nave p.pred IIW appicWon end tet the work will be 4r NCorOeTA w+lh San JowuN eeumy pdMantes,state Iawe,_and
<br /> . ,.Iaa sed regulations of ted San bpuin Corot,
<br /> 11eru,causes,w[terued e0re's siputwe Chita"ted fobwirp:"I CSAIIy that In ted padOrm.nce of the wrY la vMkh wh prmh Y Issued.1 049 rot t
<br /> a npwv all,PrwA N pKh tlrarewor M w became Publics To wer.nan'e COmpeMilbn Level of Cdifornio.-CenpsctWf hirNO W wDCeninatlbq O"wo
<br /> i '. yrdty Dta fowwNO:9 prY/Y tel n ted psrtrnance el IM urea lar wrnCh!hh grmlt Ia hsu•d,I f1,sII employ prwrle Pufleet to vvrtmMl cen+prlM
<br /> '..tkn 161e et emmarrdo:'
<br /> a4r TM pNrarlo,.rift W for Ca7
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<br /> f5 R DEP ONLY .I 11'
<br /> ApPEe~Ap w od by �.T-,GI .vat pals t� A
<br /> b en ,Grow Yap•etlee hy.. - — Ofie .. final Impaction by_ Den
<br /> AdA,bne'Cerrerana'
<br /> Appllc.et - Return all copies to: Su Jo.Rule Cwnsaty Pell le Resltn Services
<br /> tvvl roses. l tlesith PeralHeServs Ser i`((yyj1
<br /> t" HS N Sao Ja.auie, P O Do. 2000. Stta CA 03201 v 4Ci
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