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APPLICATION <br /> 00 yy <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S RV11" <br /> ENVIRONMENTAL HEALTH DIVISIC 4 <br /> J• <br /> 445 N SAN JOAQUIN•PHONE(209)469- D <br /> P O BOX 3R8•STOCKTON•CA 95201.0 R! <br /> PERMIT EXPIRPS I YEAR FROM TIM . <br /> (Complete SD Triplicate) <br /> Applicatim a henbl mRh b San Jnquin GNnry for f pennil IDI tmftruct anNot infull tel wort herein dt+criled.Blare applacnim is m m comp once r'i _a <br /> Joquin Caunry DewloEmem Title S^hlan 9.1I ID 3 and Section 0.1114.3 and the Ruln and Regulations sof Sm Joaquin County Public Health Service. <br /> Jas Add. 4SrirzL' j11 4Cf1<: G4..1iL� bot alfe/Atroa<Ie %/1f��./•: <7 <br /> J <br /> O.'.Nares " •/ 'h/^ ,:AdOrna , <br /> CantaKla rv^ . // drtf t'J+-T! • ('_J-•l�/+r^— LTC<n1<N0. <br /> YPE OF WELL/PUMP NEW WELL 0 WELL REPLACEMENT I I DESTRUCTION Ll Out or service well LI <br /> PUMP INSTALLATION G SYSTEM REPAI9 ^ OTHER 0 Iscoltorirw Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (,1 <br /> [1 lnduatrW O ODen safom ❑ MMIKe Du of Wee;Face.~_ Dr. of Well Cw+q <br /> EI Datwl,it/pNvala 0 G,"Peck Il T,&cv Type of Co"--_ swobcelbrw <br /> 1•I P asav I Onw 1100's Depth of Gaaul Seat TYpa of Geoid <br /> I 1 ww w _Apaea. DWh I I EPHl,n SuHace SM I...~sv <br /> Raya Woe!Dor,, U Too of Pump H P. State Wole Dona_ <br /> WON Oweruetwh 0 WM Dwarwue swliey Material a Depth <br /> Doh_ tiller IYurlal E Depth J <br /> rTYPE OF SEPTIC WORK. NEW INSTALLATION 44 REPAIR/ADDITION I DESTRUCTION I INP PKw ba,2 permrtlea A aAAc .ewes <br /> evel�blei�2001w1.1 <br /> Iew4Ytiarl w eeM: Rea4ance_ ComtiwcW A- Ones�^N?L•(C� /I'J!=,.� <br /> libo bey C4 Pv'aaS walla:_ Naurbl,of tee ootin <br /> Chel Of DIM w a empth of 3 feel. depth <br /> $11IM TAPIR 3 er- 0 TWOMlpT ceeetnn,.,, sv.}0,l No. Cerparmtrtu <br /> F%O. TREATMENT PLT.O v Method W oepoeM <br /> D+el,aea w nwnel. Ww !(->,- Founenon / Magrty Lw <br /> LEACHING LINE CR No.s L"ra,of leave 4 ,L <br /> — Total WgtN/siea <br /> FILTER IED O nascence w nal,wt: wM(.,,,� Founoatoti r^ PMWTV Lw 7.0 <br /> t <br /> - ! SEEPAGE PITS M O"'N Vv, S. r' <br /> SUMPS LI Native w eo anew: wr FeaRaeatbn �T _ PropanY Lw%n <br /> DISPOSAL PONDS 0 <br /> I I IIFwY aMrfY IMt I React peepared Ihy appYCMKn Mtd iNt M rOrl•.M be dPne in KtaaMte Vats SYf JPaal�a CWMy wdNKw.<ttM Y•M,arW <br /> nelea <br /> and eepwelww of the Sen Joasulti C %y <br /> fMM l,ARwe w Owed O Mi s PSnenRe ce, "IN loawuq: 'I cl,hfv Rwf n 11w FIM/mm ms of tel wan IDI vdabh tel pennat a awaited.L ehN rot <br /> -PROP"DIM weePll In aUt41 Reveal,w we EKpne subset 10 wpttiwn f tVIrIpMY1M i of Gsw M CPnerKtN.hwtrq ce aIACPMtKt"wavusewe <br /> I Call, the IoaOwa v: 1 cwwy Ileal n FIM Fee ca, Is, of mw wa!fee Wvth RM peeM w wunp.I a%" 41,100 penaw nlsleat w wonmM'a compo" <br /> flan lanes Fall CAWO"w.` <br /> The eRMcMt el" eel fl,all sawO Raw. Ccar ceee beam"M rFwrw a" <br /> FOR DEPARTMENT USE ONLY <br /> Appk~AeeepM by —_ Da./•[J '7 Ane (/ <br /> a IJrow Ieaapec W,OYT D e y� . Fol tewwroan h <br /> n �7 <br /> y A<weecow Carvwan:4t-.2 '42 rL,ff Li L Al D O r� <br /> A nllual etarf al Fall• te: Sn lo.auln Camty Puslle Health Servk'e. /'4t/ WZ5 er <br /> at <br /> FMallla revml4'Lnim N _ <br /> v 0c ' JSF.3 ltm. 9 •� ZS 1 CI <br /> ��< Fee Ayg1NT DUE ANDIINT R(MT+tO R(Cf NVD BY DATt A(RMl Pup <br /> w<o c- o f R <br /> //q .00 31S 73s - 3 � r 9 DSII F <br />