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I u <br /> APPLICAT:UN YUR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC ELEAL'I'll SERVICES <br /> ENVIRONUMUTAL HEALTH DIVISION <br /> P O BOR 2009, SiTOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ,Q$LL T EKVIIjt$ 1 YEAli YItQK_DA1'E ISSUF9 <br /> L (ComPltte 1D Triplicate) <br /> Ayplication is hereby Ade to San Jwyuin County for • Permit to tens;rva and/or Install the York Eer.In deserlbed. Thl. <br /> applicatiop Se Ade In eoti with San JoaRuin County Crdlnance Nu. 5411 .cd 1W aril the Rule. and F.vlatdons of San <br /> J011 io Cowty Public, Health Services. <br /> Islas Job Addes. _12%Y/ 4/ /"i i' \c!i'4n.•r'or- �li`Lr / .r r/'n Int Site/Acre /�' "Cr <br /> _- v 1'*.✓.��_.— age <br /> Owh,i.Name nE+..,g5 /L!C ("127F/Y Add-... +!=_-.f__dL�Jl��-a_T.+ '7�'J Phnne - - 1-171 <br /> a1d"S1.77_�_'.wP.'f�n.'r a'L _ L rcrnse No. / Tf S_Phone_ r 1 V <br /> TYPE OF WELL/PUMP NEW WELL ❑ e4tLt NE:.ACEI.ENT DES iRUCTION 1.tit of Servlet Well <br /> PUMP INSTALLATION =i SYSTEM NEPAIR :i OTHER ❑ NoritorlriK Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER Lr NES _- DISPOSAL FLD._ PROW. UNE <br /> ` FOUNDATION AGRICU!:URE WELL _ _ OTHER. WELL PITS/SUMP (II(-)� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT-ON SPECIFICATIONS 9n <br /> 11 Indvslrrel U Open Dili ❑ M.ntec• Dia of W.0 6u+soon-- - D... 01 Wan Casing r <br /> J Domnpc/Pnvue CI Gard Park ❑i Traq Trp.of 7:"rg <br /> ❑Public Il Omer U Della Depth.1 Gro.n Sea+ TVW of Grout / <br /> Iprpatnn ApMo.. Oaplh ❑E..14111 SwrtaU Ss+l IniWad Lie_- <br /> Raper Won Doh, U TYpa of Pump If P _ Slew Work Done <br /> WN DsitUction O Wan Channels, Se.l UM mterlal E Depth <br /> Depth _ Piller material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION..-I OLt(RUCTION C: 1-1.sepur avflem 1.1mnled d pnbl¢'sew.1 o <br /> waraba thin 200 flat.) <br /> Ih,lelatipn rniR a•rvc Rnidenca 1/1 Comm✓dIN_ OTer <br /> Numifar of kvbg vmta:_7- Number o1 bedn"rY, 1_ <br /> r CNgc1H pl.n%to a depth of 3INC -__ _Wlar table depth <br /> - SEPTIC TANK 0< TVpenNlfg r/' �''/'�- _ C.paaty /6 tr No.Companmsntt =� <br /> PKG. TREATMENT P.. Ll t Method d:Dapoal <br /> Dlnanpa x neaeyC Well 11Z- _ Foundabcn /G' Ni Ren,Lina �n+ <br /> LEACHING LINE No.b LahRh of line. _e.- - TOI.1 Ienpth/,o*_ + <br /> FILTER SED O Dimlica m harass Well Fnundanon _ Pmpar,V Lina <br /> —9-:: <br /> SEEPAGE PITS wiOepvh 1� r Si+e S Number v <br /> loo, SUMPS LI Dole.to neamc Wall 'Found.non=0_ Properly Line 61--le <br /> DISPOSAL PONDS 0 <br /> 1 hereby c.rtlly IMt I no.plwpered Tit epphcabon and 1Mt the ,rok wd'to done in arcmdanca wdh San J..g.,h County oram•nco, sale awe.and <br /> roles and rpuabon.of Ina San I.RWn Ca ntY <br /> Home owner br hcen.d agent's agnalure camLay the following. "I c•n.Ir lul m Ta pedor.n+nce of Te work for which this parmrl Is nsued.t ahalf not <br /> empbY eny pHeon in svtn rrynMr b 10 become.ubpU to wpd man's comoenyaupn IawY of C•Yorn.e."CpnIOclOYe Mting or.leo c.nllu Ing-pnlNra <br /> Unifies the foltowing:-I canis,Violin IM p.rfwrn.•t.of N:•'nork Iar h.1h Tis p.rmrt ra nsued.I.hall*hni person.eubl.c:H,wodrtw.i.comPanaA <br /> lion laws of ca ifank." <br /> The appiics t ewtl call for W raguBed inspect s. Complex drawrnQ on r.vfraa s-ce. <br /> Slgnad% ( ,� ll�Y1: T,vt �/r-'z Date: <br /> OR DEPARTMENT USE ONLY <br /> . Appllolbn Aeceotw te Dau s-ateg Arca <br /> loo, - /11 GEWf In•paelbn DY r �U L Date, ��. Fin.l In+Iachpn 61"� yL <br /> ddnbh,l!:pmmams: <br /> Appilcmt - A.turo all coplae to: SAN JOAQUIN COUNTY PUULIC HSALTH SEIIVICES <br /> ENYINUNMENTAL HEALTH DIVISION PERMIT/SERVICES ( � <br /> ` 445 N SAh JOAQbIN. P D LOX 2009, STUCATDIf. CA 95401 4 <br /> r AMDUWNT DU[ I AMOC4i nIMITTEO ����/�(;;a��sgqrr RICJfV�ID dY GAi( {� PERMIT NO. <br /> IN1J <br /> .tw taN raty.r. f LLA-W � I C7O 14I— <br /> w,., <br /> 6. <br /> L <br /> L <br /> im <br />