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SAN JOAQUIN COUNTY PUBLIC REALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 xT �LT(3 2D-3'fi6-02 <br /> P 0 BOE 2009, STOCKTON, CA 95201 5iiema 44 /f—t-5 <br /> orpMTT EXPIRES 1 YEAR FROM DATE 155UED FAKING <br /> (Complete in Triplicate) <br /> App11at1on is Wreby sada to S.v Joequln County for a persalt to eonetruct and/or Install the wort herein drscrlbed. This <br /> epplleation to suede in compliance vlth Ban Jaqufn County Ordlnanee 00. S49 end 1861 and! the Rules and ReRulatlon• of San <br /> Joaquin County fubllc Nealth Senlas. <br /> Job Address LlE '7- N T�R,G�K, TDNL° /L.O C.IY_�vC4C � L°t slte/Arrr,Re <br /> Onttr'e N.I.t. </ .rAA }/7u5 lif�Hueeaw —�SA7'�!F' _ Phone 1 e7 <br /> Conhacla B %A+/ra-A�ir(Fzt 2bZ$ E. /�R.1�+ SrLcenseno.:�/�7_( '_Pnone_ d"�3 <br /> TYPE OF WELLIPUMP NEW WELL ❑ WELL RSF fl DE ST RUC TI - <br /> PUMP INSTALLATION G SYSTTEMEM REPAIR <br /> R OTHER �T/ bJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO_ OJ+e''ww <br /> FOUNDATION AGRICULTURE WELL ___ OTHER WELL___flFe -- 410,01 , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> G IndaalnM U Open Sonars ❑ Marnesa Da of Was E.cevabon -Dw"of"WaFCaa"fh <br /> f 1 Donrstcf Private ❑G,"yocY C Tncy TYa of Caamq. ____ c^".•"•""" <br /> I'I P,AIK 1-1 O'hee fl Delta Depth of Grout S.M <br /> I I lnt. _Apaoe. Doolh I IPoll.-In S.,fsa Seel ImISINd by (tit L(„ QAf�LHL tri/ <br /> 0a w� <br /> A&W Wok Done U Type of Pump H P. Stela WOA Done_ HST LG PY./L N PIC <br /> Woo Dee von O Was da how SeellnI, Rst.rlal a Depth <br /> Depth tiller Material L Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I CESIRUCTION 1 1 !No"PIK svnem prnw0ed.I gAN.c w.v.r n <br /> ava4b1.vmiM 200 feet <br /> bMnUtbn v Buve'. Residence_ Com cwl_ Clhr <br /> NtRnor of[wnq u,ele: _ Numbr 04 o.d.nems U) <br /> Chwic w of 905 b e dWh&13 N.n W.I.,tab&.deem D <br /> SEMC TANK ❑ Ty 11*fO Ca9aeM No. Convow norm <br /> PKG.TREATMENT PLT.❑ Method of Oiapo" <br /> Distance ro nearest: Wel FouMstan Property L" "7 <br /> LEACHING UNE ❑ No.\L"th of Pines ToOI Nnpth/Fite G_ <br /> FILTER BED ❑ DMtana 10 rsrear WN Foundation P,o L+v <br /> SEEP-AGE PITS 11 Depth Sue Numor <br /> SUMPS LI Distance q nowt eat Was Foundalgn__ hopny L ne <br /> DISPOSAL PONDS ❑ <br /> 1 he,eby er,*v rh t I hew pr.pred""appacahon and that the v,aa were I,0 don.n.ccad.nt.w„th San.loaquN county nrd-ne"C" star.4ws,arM <br /> rtdea end rop,Aalwn.a thqa <br /> e San Jo. „n Csty <br /> Nene OaA+w a 4e,stl epee•'[o"tues IRrb/M theloaawn0'"t csrnfy that N Iha Wo,nana o1 the veora la W,ich thin parent a n.u.d,1 ahM no <br /> en'01a,.1,T perces in aYCh mMwW N 10 fMCORM aNp1.C110 wq e,sn'e tV,MH,wlq,111we Of C.O."'A.'Convww's hxmq a W DtonM1Kte f;sgr.wr. <br /> e w"flea the tobwvq:"I ere[y that in the prfa,w,es of the w k 1a M,Kh thin p. t n issued I~employ persona subleet to w04 mars'a eompsnw <br /> tion WA Of 04110 .' <br /> The .1 to for of uv.d aNp.cttorM. CaMele dr.wrp on hsw f i scar <br /> Spred Tito: <br /> V TM[NT USE ONLY <br /> App[F~Att.o W W Den A. I <br /> PR V Groh at N <br /> Ilopectlby rSsn FM Inspection by Dan . s�9✓ <br /> Addhie ei Cr«nr,s: <br /> Appltc.et - Rate'. .11 eoPtsa to: Nan Jo.qul. P .ty M,1,31. Ruth Aerw ice• <br /> Lta•f rov�.ntLL <br /> Health Pv,'1tis...Ice. <br /> aaa R has Joequt.. P 0 Rn• 1000, Rtan. CA 95201 <br /> RE AatpINT W[ AY011Nt R[MITT[D „ Rtet"D BY DAT[ P(aMlt hap <br /> /wt0 <br /> `' `y 7 � LI/2 Z 3 <br /> .,aM <br /> r <br />