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1 <br /> APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIBOMIENTAL HEALTH DIVISION - <br /> 445 N SAN JOAQUIN, PHONE (209)498-3410 <br /> P O 901 2009, STOC=TON. CA 96901 <br /> � ��.�'�SFi�ug _ YEAFLI+H011 DA'1'� I33[1SD <br /> (Complete in Triplicate) <br /> Applieatioo is hereby tme.to Sas Jom"in County for a pomit to construct and/or inatail the ,Tort hareio "%CrttleA, Shle <br /> pplioetioe is mLde in eamitenee vitt+ Yen Joawin County Ordinance No. 549 and IM wd the Ntalae er NapLtiorre of den <br /> Joer)ris C.omtT�Puub�liic Yealth services. <br /> AVE. <br /> Job Address ___!�-1 �D yL—T� 1�� —� CIW�,=� �t Lot Y!N/ACr*W �O <br /> Owner's Name .� f�[,�C¢�{� Adorec. ��fs� l ddf�LL7 /{✓� 'r >( Phone <br /> N"-44F <br /> �� Mot�sS <br /> CenhKtar --_Address_� __._... �_License 140. Ph" <br /> y F WELL,PUMP NEW WELL U WELL P.EPLACEMENT fl DESTRUCTION Q Ort !ee Yell <br /> ►UMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER D ftelt4e'inA veli n <br /> r"TANCE T01E EST: SEPTIC TANK . __ SEWER LINES _ DISPOSAL FLO.�.�PMOP• UNE <br /> UNOAT/ON — AGRICUI.TURE WELL OTHE MT>fl>fV1NPE1 <br /> INTENOED USE _TP ElL PROBLEM AsIEA CONSTR SPECIFICATIONS <br /> n Ir,dreerw O Open Sotto!" i Manter• a WWI Excavation Db.M Well CaeYq <br /> f l De twtk/private 0 Gravel Peds ❑ Tyve of Camp__ � <br /> 1'1 P,Me 11 Other l DNw 1n of Grout Seal Type of <br /> 1 1 Imprfan ox. Depth ! I Eaatwn SUMO IMINba by <br /> Flepdt Werk Done rpe a Putttp -- H P. `lata Wort Done <br /> Wes Oeanretlert O Well 010*so bealinl Material 11 Depth <br /> — { Depth 1'ller Material 1 Depth <br /> IT EP RK; NEW INSTALLATIONREPAIRiA001TIUN I I DESTRUCTION 1 1 Wo*epic eyetem parIT101101111 r past W—is <br /> waMOM vM1,Y1 NMI.1 <br /> MaeAabrt wA serve: Reerdena 14 Corrrnarc!N_,_ Othw_ <br /> t <br /> Nrr+w of s"finite: Number of bodroo+ns_ 1 <br /> ■- 1 CMrecew of soe to•depth of 7 hta: Water tee+.depth <br /> SEPTIC TANK )( Type/MIO s03E�_ Cepactry NO.COROorertwm <br /> MCO. TREATMENT PLT.0 Method of Draw <br /> Dbtana to newel: Wel 18024 FourWnwo �Er PropertV Line -orf <br /> _ t <br /> LEACHNG LINE No. J L.wgth a Knot -� +*fl Totel brl"h/we <br /> N - <br /> r .ca w.c <br /> FILTER SED O Obtance to nevem: Wel Foundalwn P 0WIV LY,e .�r� • <br /> Ziat . <br /> "VAOE PITS I 1 Depth S," _ Nvntbw_ <br /> SLOW$ LI Distance to" ww' Wen _ Four '*room _ P►opa1V Lim <br /> Ow"AI PONDS O <br /> 1 heteer aerie that I have prapbed mise applkwwn and thV the work ver be no In e.cotdanca with San J064Wn p.ntrey WdWAMft,ante ISO%end <br /> ... rmAea eM+rptiwto^x of nM Evan Jee*r+n County <br /> 1te+tr ew+tw w treanead aOar,t'e elOnea+re aarMle the hyNo,+.rq 'I comity tit M tN perlpnMnty a the work Ip vMJett thea peatlM N Mored.1.fill tea <br /> a+hptev any prreon ss nonnw as to bromm a 10 worrmen'e conpowewn bee c+Calilanb"Contraewr a hMkq a McMM+eeminY e1E/eef+m <br /> L I in a the we,►to wh,ch MN permt M betted,I OW wn010y pereO+M Neleet le wfwh w'$OSWOetlee. <br /> ..relic the IoeoYtr+tY� � C+rtNV <br /> Ben laws of <br /> / C Ormdne tNtwnp On rtivlrr s ude. / <br /> $qmod t7 <br /> Tnie <br /> j ' FOII ol►ARTMINT UYE ONLY <br /> L / *.-, r beta ca Ante <br /> Apper_atr n Accepn✓f by <br /> P11 of oreut Inapect/On by DNe FMIeI Ir,epertl0n by OMe I <br /> Addlino"Corwments <br /> i appl lrxnt - nnturn ell voplva to: nen Joaquin County Punlie Health Servic•a <br /> lniroeerntel Neelth Paraft/lervicea <br /> •441;rh nun Jnequfn, P O pox YOO9, VNn, CA 952101 <br /> is AMOVAIT DUe A=?'11MIrT10 klx 011101%,1011101%,011101%,1110 By DATE pEAa1 N <br /> eO <br /> vro <br /> a"t.a <br /> r <br />