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APPLICATION FORP67LIIIT Intl IT <br /> SAN JO AQUIN COUNT- PUBLIC USALTB SSRVICS� O��' { � <br /> SNVIRONUM AL URALTH DIVISION JUN z g 1991 <br /> P O BOE 2009, 7 <br /> ETONCA 95201 <br /> 209) EPJV!0()'4MENIALHEALTH <br /> PERfv11T/SCRv!C,g <br /> RY <br /> PSIT RXPIRSC 1 Y AR PROP DATE ISSUED <br /> (Complete ID Triplicate) <br /> Application t. rereby Mae to San Joaquin County for • pertkSt to Construct and/or Insult the work henln described. This <br /> apPllcatins Ss scads in Copliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and atpi&tlens ot Ms <br /> Joaquin Coun•y Publ:e Health Serwlces. <br /> Job Address �C �; E l . 'k.,,1_!(. . F't� City�.Ll� Let Slee/Aeresde <br /> rl <br /> pwraal N•n.• 7.1�F'�_yr:_�! �•:.J.f��l .tdd,on ►hen. <br /> D <br /> r� d License <br /> Cgnlracla 'Y `n•.e' f -�' A. Address '(-' IF/_. .�. L.�%:.4' „ <br /> TYPE OF WELL/PUMP NEW WELL 3 WELL REPLACEMENT (' DESTRUCTION Cl Out or ltorInvorwce Well <br /> PUMP INSTALLATION T`- SYSTEM REPAIR f� OTHER ❑ NonStorSrlE Ne31 CT <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 <br /> Bonom O MonlKs DK of WN E.Cow•lron ON.nl WN Cowq <br /> fl lrMunr,el ❑op" SpocdN:olatm <br /> U-06-14414/►'Note D G,,*Pat ❑Tac' Trp o1 Cwhhg <br /> Cl PIAFe 1'1 Other ❑Delu Depth of Grout Seal <br /> Twp N Grout <br /> CJ hrgenonAppq.. .pth D E.sn $.nice Seal ImK b <br /> 1a11w <br /> i1�._-�.- l•rN►..—t'r�J.! Sul.won 0011411 --�� <br /> ROW Won 0a1e id <br /> TV D' TV"of►urn0 - 8•sllrl[M•Grts1 [ MP- <br /> WOO Destruction D Woo Owtult l Ptlier lUtertal [ Depth <br /> Depth d rbkc 600••1 w <br /> TYPE OF SEPTIC WORN: NEW INSTALLATION D REPAIR/ADDITION❑ DESTRUCTION O .Na 1 �!11H1 t�QPM»� P <br /> Ine1N•twn vM all Re el'""_ CsmMreN_ OthM <br /> N.mw of kwmq''rale: Numb•'of b.d'onm. WOW Igs,depth <br /> Chat",of WA to•depth of 7 f.H: i cowry Na.Corortwenb ' <br /> SEPTIC TANK O Typ.IM1q _-- Meshed of 0*MOW <br /> PKG. TREATMENT PLT,❑ Foundation plopon,LMu'�--� <br /> DnurK.10 M.IKI WN <br /> at HrP,Oo v <br /> L="� <br /> N0. [Length of IIMe fo.Irld•1rOn hepRY 1.1M <br /> FDaunt•1n pUest: WN&n NumberI Depth Feundatmn_ PrsOetr LirNI Oauncs 10 na.rell' wN <br /> n .M'KH, Fble 4w.e. .nd <br /> 1 hM.bY Nn.N Ince I nm p.sp'.o qo' rod'C•1'on•nd 1M1 IM Yrpr. wN1 W OOM i •^a,Gnceof the <br /> Stn J lot*tuin 4h NY 'rat a,good.1 sh.N nor <br /> ryMs•rid rpulgnu.s PI 1M son JO.qu'n Cwnty 'I ceroN th•I m IM ce a este 011th.AO'k Ip whKh Ihra p care <br /> Horns pans,a I,Cene.d WM.Wn11u:a can•IaH the IO.Ovnnpof t 10 aprkrnM..COrnp.n.•. <br /> .mpl.Y.n,psreon n.1 h 1h.I r P•worn. <br /> .m Ttwc'11 .0'k•a,Aw�Kn thNPsrm nt a.wd'lo•NN smob1w 1N'salo�sl bMc ewtytpnl.K'w.q <br /> e•nNw 1M lobwnn9. <br /> "on VM 01 CMilor NiS ) T <br /> The.PPw <br /> sn1 must uo bnN rK.^b il,,pclarns Complete a•" 111 on Dow <br /> - 4- <br /> FO DEPARTMENT USE ONLY _ Area <br /> C•-1 � Deis / DIN• rr I' 1 <br /> APdKel,on ACCpled by ( r <br /> De1e fines Insf»chpn by <br /> Pa p 0'",Irapectbn by <br /> Adomonsl Cemm.ma. T PUBLIC NEAILTN SmtTICES <br /> Lp tot SAN VIN L NZA <br /> Appl t<aot - Mtura all eop ENT .NJOA UIN. p 101TM11St12000. SS1OCKT�ICCA *5203. <br /> EEOI _ <br /> eeq .1 JOAW IM. too, sl0 <br /> a sQO.lO W DATE <br /> FIT "w'T Out A'+OVNI NINA^=0 C H <br /> IarD1. �. 4 ►-� <br /> trEJ <br /> Der (41 <br />