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APP(.I CA,r I ON SR 4t <br /> ,TAN JOAQUIN COUNTY PUBLIC I Y9� •ERVICEN jJ.q- <br /> 1•:NVINONUMTAL 11F.ALTII I li{ <br /> 445 N SAN JOAQUIN, PTIONE ( 09 �6,0-3420 <br /> P O BOX 2009, STOCKT(1N, �e <br /> ti��- PElt ;T FXPlltras I YE_ L �R(M B RI tl <br /> (C'omp.l(:'to in Tri pi <br /> Appll cation <br /> 1. bereby rile tc San Jo@4uln Ceon Cy fur a Pesti W cr.m.tra;t and{or Ina Call the vork hereto deacr lb.d. This <br /> application is rile in cowl Once vlth San Joaquin County Ordinance No. '_9 and 1862 and the Rule. and Nrviatlom or San <br /> Jwquln County Public <br /> Public Health 8,1eLt"icae. <br /> Job AddnaL._ ---r i17.(,(.f-i _/'/✓-r,er_ ct .�Ln{A-rraKe �(_' <br /> i1! <br /> Phone <br /> Ownu1 r4ame <br /> Cantuctol Ed Y� _.__P:td.tf--jl.�rt��s.�_L.-n% - L+cense no.�-SGsJPeone <br /> TYPE OF WELV PUEAP NEVv WELL ('! WELI REPL AC6MENl ;! ice well 0 <br /> OESTRUCTION I l Out orsioB" ryl Well ❑ <br /> PUMP INSTALLATION L; SYSTEM REPAIR .' OTHER ❑ <br /> DISTANCE T_0 NEAREST: SEPTIC TANK ..—__— SEWER LINES _—_._..._-_' DISPCSAL FLD.__ PROP. LINE _. <br /> FOUNDATION -- AGRICULTURE WELL____UTNER WELL_._ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBI EM AREA CONSTRUCTION SPECIFICATIONS Dia. of WIII Calling _ <br /> fT Ir+tluur+tl ❑OI»n Bonom Ll Mameca Ore OI well Er U.Jl�an_ .---- 0".SpeofCWe,] <br /> f I Oomaahc/Prlvua LI GrsvN Pack I'I TracV Type of Citing __-- <br /> I'I Podflic ations <br /> I Of", 11 Dol,- Depth of Grind 5.a1 TV"of Grout --- <br /> I I ligation —.. Aamae. Depth I I Eason Sull,es So.,Intbe.d byAli Work Done U TV"of Pump _--- H.P. —_—_ _ State Wolk Dad. <br /> ng _ <br /> ReeliIycertal-aY� hLL_"1.•A: !'}) <br /> Wall 00.1.11mm ❑ Well Diameter r (� <br /> Depth,-- IYL.r Material a � - 1 <br /> 7Y PE OF SEPTIC WORK. NEW INSyT ALLATION' 1 ff EPAIRrADOTOW j�t CJI(r Id waraabbte tic <br /> IOD I"lad d p"enc u.wr+a <br /> Installation will aeon: Residence l___ Cc umrcnl Diher SAN JOAQUIN <br /> PUBLIC HEALTH`Et �� { <br /> NVmber of living urvtt_I— NVmCer oroam --—_ CN'JIRONMENTAL HEALIr.,. / <br /> Cha.ctar of WN se,a dopth of 9 fast �'" Winer tabs deptl+_yy� <br /> SEPTIC TANK ❑ Type/Mlg---r— capacity—_ { NO. CemVanrrnfe I <br /> PKG.TREATMENT PLL❑ Method of Oispewl _ <br /> Distance to nearest West Foundation_— Progeny Lira.d <br /> LEACHING LINE W No.b Length of lines Tool IenbtNaiaa_40 <br /> FILTER BED CmI Dwil.ce'o 0lial: Well. i <br /> '.'_ Founoehon lf' I•• P,ornv Line <br /> SEEPAGE PITS 11 Own JE7r Sire_ 1(' I` _ IJumper � <br /> SUMPS LI Distance I.mouses �].1:— Property Line/ _ <br /> DISPOSAL PONDS ❑ <br /> 1 hereby comity that i haw PrOPemd Ibl,application and that the work will be o.m in ece.oanco with San JoaOuln county mdinancos,state Iews.and <br /> rola,and egul.1mem of the Son Joaquin County <br /> "i <br /> HMIs owMr or licensed agent'@ signature bonds,the following'. seedy that in:^n pndorinenes pl tM week for sottish shit perm)b OB-PIE I shall not <br /> empty any parson M lul msnnar as to became aubmct to womimli comp.nsalion kw,of California."Conlraetni s niring or suPcontnctinq signature <br /> cenill,e he foMweig:-I certify that in:M parfatmance of the work for which this permit Is baued.I @hell employ Persona subject to wortmsn's campanu <br /> film Is.01 Californla... �7 <br /> The epVl¢rol muss aR for MI r� W ono.ComdjrE drawraq on/.V....aide. <br /> LI <br /> $iq o <br /> .�/ .'P' `, _ Tapir_.S_..Ls.i-L--- Dne: <br /> FOR DEPARTMENT USE ONLY � �1 <br /> L44," <br /> ' <br /> Data <br /> Application Accepted by <br /> lnspoctbn by _ <br /> ��/ II <br /> fjrout <br /> t _ Oam."'f-'� Final Impaction by <br /> L <br /> Additional Comments: — <br /> Appllcnnt - Return all colic¢ to: Be- JPagnln County Pnbilc Ileal th Novice. <br /> Envf ronm,:n Ul Healtn Pvrml ti Sc rvf can <br /> 445 N Nm d",olutn, (1 Boa 20'9, Stkn, CA D52111 <br /> 1 I FEE nMCUNT DUE AMOU AteurrED RCi FIVLO ev p f �W MIT NO. <br /> � I <br /> ln �i <br /> u.3a / <br />