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y AvnL1L,'1J04 FOR PERMIT
<br /> ! SAN JOACIL'IN CCUNTY PUBLIC IMALTIS SERVICES
<br /> F:NVIhONNg•9TAI, 11EALT8 DIVISION
<br /> P O 1303 2009, STOCKTON, CA 95201
<br /> (209) 468-3447
<br /> P.'<B�(lr E:•Plf3&;t.1_ 5e ti PR0�12ATE�S,SUKD
<br /> lCOmplete In ir:pll,'e.te)
<br /> Appllcalon I. Drrehy Ped>te, r :u4r•L^. Comet for a Der:- 'o ccna,ruc: ea.1!cr inrtall the vert rere:n aaecr Ib,4. TDie
<br /> appllaatton 1. udo In cla�r::arse v:;p So,: .iMRu:n Cc An!y Cr.....arce H>. 54,1 and JE52 and the Pulea and P01P IADSon. Of San
<br /> JosQuio Co•APty Pibllc neaat S.�trv'lce.. /
<br /> r lob Add,.., !V /^�C•�/' ..____ [nv -_- Lot SI[e/Acrem,
<br /> -_ phone
<br /> OwM,'e Nam• ��pr/��_--_.-.___. q.::rt.v _ �5._�O N_�_'.---
<br /> ConLac!D, ISL, !�� .slay.=`'.;..::i/. rlC:.._,r.--___L :e,'vNe/%�YL` _Pv.trf'6en7zt- 2e
<br /> TYPE OF vtELLIP,_ ' t:'+'.E-- °E%.nCF:'F'.- DESTPUCTION :, -it of Sarvlca Well 0
<br /> _
<br /> DTMER I nitorim Well IT
<br /> f'V AaR ,r.S';.:_a T:�.>. "' :: S'i;• PEvAR :. I
<br /> tif..Fo =:S'CSAL FLD._- PROP UNE
<br /> DISTANCE TO NEAPEST SEPr.:{ ;a!p; -'---'-"' PITSr5UMP5 _
<br /> AuaiC-:Tl"E:'=_L__- OT.,ER WELL INTENDED USE TYPE OI 1.1!_ vu O:EM A-EA C0'a5IRUC7''O1. 1Ft C_4ATIONS
<br /> 1' Indbu,a ._ OMr.Nurtam ., f1a^t.0 ..a a".ye. 6ce.seen._ --__. 0•a o!Wan Gurq
<br /> r r.
<br /> :run..•�•o•.q. _ _.- SYec,OU[wro
<br /> �i Dumacea P,r.re C Ouv.r P.cs •,Aty - .. TrM of Gout
<br /> PuDIK I1 Cnwr ._ Ue:n Y.c" . �•,m •. .-__--
<br /> G Inrylanm _._ APo•o. Deer^ ... Ems•,-. 5.. u•S..l n.v. •'�n. "___.-.-
<br /> A.M.r vvO,1 Done C TYw of F.-,. ___. ._._-. ^° _ _ .__-__ _.I_ 5un wo•e Oma_
<br /> YLII Dea[rDtilYun
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<br /> wUP.xvWO ` <L'✓' LS�,7-ON IN
<br /> NSiaLVi .ra.vnc care,+•wm,n•d,I
<br /> TYPE OE SEPT,{ 9p•,nec ww•r,a
<br /> to.[.1
<br /> V'r Inalallelren-It"I. Al•Nenc..e CCT^••'r.
<br /> Number o1 rv,p un,t. -._ N:•^bn _J—_
<br /> We.., pDM depth
<br /> Cr.rictp OI sod U M
<br /> • DIn o1 1 1..r
<br /> SEPTIC TANK b Tw•1Mfq �_irE+•�.L _tL -=+S Cr Goao:r_12_•<__�__ Ne.Campana+an[a `!
<br /> PKG. TREATMENT PLT-O of,D•npogl :V
<br /> fi:mrrn e,-er n1 Nen�(�" Fo:nJ.nen��`�'._ P•ovnr,L.na l .
<br /> LEAC*ING LINE ,tr nc 6 Le ,,n
<br /> FILTER SED . . G:.:mra m -u nt ..n /61,•_.- Fc..r,y!•Pn_/�___ POM,IY Lm.
<br /> SEEPAGE PIT$ iC Orr•✓
<br /> SUMPS C: .>•un.a rc,+ ul Ww__amu- Eo.nepwn�L__ P,nMrtr Lvw /d
<br /> DISP05AL PONOS l • rl
<br /> 1 np.0y c.ndy 1",1 n•v.w.w.4 rn.y q,yr<A'.m•-..... .0......>r n.,br Jana m actu,a.nu wN.San JpaPu•n<DunIY oM,nan[o,.tab 4vn.IM\'
<br /> ru',ec ena npdpon.of•r.S n luaum f
<br /> nom.ewnp or iwenaeC ryach Ppnetw.wn+�n vr.!c ?may r• +•r"•'in P•MM,n.unaa
<br /> of m.won lo,wh4A IF.,ppm,[..n ad.I aMil rw[;•c
<br /> .mDIOY env Munn v.wcn rrun,vr u m Dntun r avnrtc•:o w„a,-an c cu^vnrurtn a+.c o!C.abrro. Ccn:ucbi a nnnp or aub conuatlrrp ppnpuu'i
<br /> Qr111Na IM iDne+.,n2 'l cpbfY:e IE i['ne Y rn•wcn,O•.� P 11 Pa I n ..Led.�aMr1 employ ,,jWn.Subject to w9rkrYn'a cemMnM'n
<br /> Iron Uwe or C.10,11.
<br /> The a04'rcam myA /�r
<br /> vP:fur W/r/e'l .d [I n..r o >. a ban •: cr., -. , .•dr
<br /> Data
<br /> �Q -__A .
<br /> J _ POR DEPARTMLuT USE ONLY •'
<br /> A"ED.Fon Accepu]Ov /u-cT_cy`
<br /> LAIe___—. fmar bueepon
<br /> byL __,_ Dm
<br /> :PA W G$00 IDIPaclnn DY —.----__._--.
<br /> AdOniorol Com+Mina. ___---------
<br /> Appllcmt - P.atprc all cDDSe. c: :AN IUA,i,H :OLWTy PLEL:C HEALTH SU..IC'CS �
<br /> 41l'IPJ.ALNTAL IIL.ALTH I11y1910N PEKW:T/SE'HYICES
<br /> 445 n s;v J(1!`:V1H, P J OOA 2009,T9 �TtICK:'r:N, CA 05201
<br /> r�lE r T Rt".ED Br � 04iF P[RNIT N0
<br /> IHULN L'r I 0
<br /> rare r / I C
<br /> AS
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