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.00 <br /> APPLICATION 3 <br /> SAN JOAQUIN COUNTY PUBLIC HRALTH SERVICES <br /> {' ENVIRONMENTAL HEALTH DIVISION <br /> "• 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 3. P 0 BOX 2009, STOCKTON, CA 95201 <br /> y <br /> .' <br /> r PERMIT E%PIRES 1 YEAR FROM DATE_T cSUID <br /> (Complete in Triplicate <br /> Application 1• hereby assde.ta Sea JoaRuif County for a yeratt to construct surd/or inae.lt the vort therein described. This <br /> . appllution I. ride in Compliance vlth San Joaquin County Ordinance 9o. 549 and 1962 and tte Rvlea W fus"tions of Sen <br /> Jok ip County Public Healed Services. <br /> Job Add - GN Lot Slze cree6 �� <br /> � uu r <br /> . Ownw'a Nano L Address J wan• - <br /> Conllacts, r^""-"` AOaless License No. Pb.. <br /> TV PE OF WELL/PUMP: NEW WEI.L O WELL EPLACEMENT i CE CTICN O Out of Service Veil O f <br /> 1 PUMP INSTALLAT:ON 0 SYSTEM REPAIR C OTHER G Monliorllf{ Voll 0 i <br /> DISTANCE TO NEAREST: C TANK SEWER LINES OSAL FLO._ PROP. LINE <br /> fOUNDA. AGRICULTURE WELL OTHER WELL PITS/SUMPS . . y <br /> INTENDED USE TYPO OF WELL OBLEM AREA CONST ION SPECIFICATIONS <br /> (] Induamel 0 Opm Banom ❑ Ma Die Well Eauwtwn 04.of Wall Gairq 6 ' <br /> 0 Donleauc/p"'as 0 Graysl Pact 0 Tock of Casing_ Sycdical:oru <br /> I'I Pudic 0 ONar Il Dein Depih c Seal T,,of Glovl <br /> I I"'.H. _App Is. Depth I I Eesu Surface S .1 Inaulled M <br /> -- _ R•near Wort Done 0 Type of Purrs, X.P. Sues Wort Don•_ <br /> j WW D.". O Was Diameur &marine Ksterlal 4'Death , <br /> Dead, - In, <br /> Macular 4 D,,P1b <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/AODITION I I DESTRUCTION INo upuc swum PVmgbd it pubic reavi u <br /> 0 <br /> a14fnevpIN.200 Iest.). <br /> Ins,allsesn Wu <br /> til nw: Residents X- Con .ci•1_ Other <br /> Number of tv'IIIg umu: z Number of room / <br /> j <br /> Chasers..1 Pisa,o a Ypts os 3 fwl: ./p�W_,1(. W.I.,lease dents <br /> SEPTIC TANK 0 Type/Mfg�p CAffm Cabaty No. CarWrtmPnd . . <br /> f PKG. TREATMENT PLT.❑ / (� M•tMd al Dufour <br /> Diaunu m reuea[: Wen /DO Foundelnn 2- Property Lin• <br /> e LEACHING LINE 0 No. 6 Length of Iines� �P�t Jain 4ngmh4e <br /> t FILTER BED --0 Ow.Is..at WMI�,�'� Foundaluul 3f� Prowrry Line F� } <br /> E <br /> SEEPAGE PITS I I D.pm S'v NumWr <br /> SUMPS LI Dr.to rlearnta WNI Founbaon Property Lire <br /> - *{ DISPOSAL PONDS 0 <br /> F I Meb,cki INt I have peen., Nim Inpiutwn aha net.he wart wnl be non• r,accorbnu—.h San Joao..own,ordinanua,stau um,a <br /> E nrle,and r"Prahone of this,San Joanun County i� a <br /> 9 Home osever or hose•,a,ai aigrelae candisa Iha Ipnowing: 'T c•rih Inst In Iha nenornunca of In.wort fa vnii Ines parml w caved. I Yup rlo.—t` <br /> __ _ Mrlpiny MY parPan n WN rlenMl 0a 10 bKIXM Wbed,la w'arLmfn'I Icurn h.u..4.al CalilpRw.'Ccirdsl n.'t hung IX-0-1-in' t"YgnANrE <br /> LaNIW the fhadvai"I certify that In IM pannllNrlte al the wolf for which this perm,i1 Wued,1 anew amp"parsons Wb1aCt to MOIEIMn a co roatnei <br /> tion L wa of Ca dorrhi 2 <br /> s <br /> The appYran /uJY I/w//�W r wad napK[gns. Compete Ouwng m/r¢/�/r�side. <br /> . \/59rIW Y R.U.( r2 '/� Tine:y�C I�:. �1T �`1^C� J� 0.10: 16-7—9 <br /> /s s <br /> DEPARTMENT USE ONLY Q <br /> App4r4,en Attended br � L. Ik(rEyi•{��'�\J\ Data —f Ares <br /> PN or Grw,Irup•ctan the Dat• F naI Inapec[ion by !" Dau��4 3 <br /> Add.."Corrvrlrlu: ��a.c�CL--s z-=. t��t—p�1n �-�jl�^..-._'a� <br /> Applicant - Return all coffee to: Sao Joaquin County PUp11C Health Services _ 9 <br /> avtraeeenl Health Peralt/Service. <br /> 445 .4 San Jotaaqu las, P 0 Baa 2000, Staa, CA 95201 'f <br /> rEE � AMDaHT DUE AMOUHL REMTFD <br /> FO ASH RECENED By DATE PERMIT NO. <br /> d <br /> rH.'a law.Ir•,Ica <br />