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<br /> APPLICATION FOR PR".T
<br /> SAN JOAQUIN COUNTY PUBLIC .UALTII SERVICES
<br /> i ENVIRONUMSTAL HEALTH DIVISION
<br /> 1601 E. HAZELI'CN AVE. , PHONE (209)468-3120
<br /> P O BOX 2009, STOCSTON, CA 95201
<br /> PERLIIT EXPIRES 1 YEAR EROM DATE ISSUI2
<br /> (Complete in Triplicate)
<br /> Applicntioa Is heretf wade to San Joaquin County for a permit to eonstruet and/or install the work herein described. This
<br /> app:ication is rade in compliarce w'th San Joaquin County Ordinance go. 1.L9 and 1862 and the Rules and A.6ulations or San
<br /> Joaquin County Public Health Ser,r�csa._T, ^
<br /> Job Add,ess /� '•�L`�^r, — City( Lot Wt Slte/Aen�wlie L` �-•_
<br /> Owner's Narms Cst,� C c'.C/T`\t.',�- r�AOCrrss�IL,.�.,��-7 ♦ :_—_L�r`�J Pnone '71�`'
<br /> Cont,acts> ti r ]4_Ad�,ess_1L�C_L'V�V 7 L'cense No.1z?�
<br /> TYPE OF WELLiPUPAP t.EW v.ELI WELL REPLACE%-[NT i DESTRUCTION Out of Service 4e_1 U
<br /> PUMP INSTALLATIO 1 SYSTEM REPA19 ;. OTHER Monitcri" Well r-y
<br /> DISTANCE TO NEAREST: SEPTIC TANK — !,Ev%ER LINES --_-- DISPOSAL FLG_ PROP. UNE
<br /> FOUNDATION AGRICULTURE'VVELI OTHER LVELL---- PITS%SUMPS —
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS-
<br /> I IMusI m C!Open Bottom LManteCe D•a of virus E.uvaton _-- - — Dir Cf we:?Casvnq _--- i
<br /> i•Dyhestrcipnvsre (1 Gavel Poch !, T,acv Type of Cavtq_--_ --- 5pt0'Ca(1014
<br /> i'I Pub1< I 1 Orae, Dear Depth of G,o.t Stat __-- _ Type of G,out
<br /> i h+,yttron -_Apryo. Owp,h two'. Su,lace Seat InsttWd by
<br /> Rvwo Was Done U Type 0 Pump H P -------_-_ Swo Wo,s Done
<br /> wee Destruct." a wom nwnet.r _- Sealltsd Material a Depth 1
<br /> Depth tiller Material a Depth
<br /> U
<br /> I YPE OF SEPTIC WORK. NEW INSTAt LATION 1 k REPAIR,ADJITItrF4 DEbTRUCTION IVO seplt Vry,e„t W mated d Pi-NIC s.rwe, n
<br /> - n tv A4AIe w'�,n 200 leetl
<br /> InstallaTon-4 Sarva RaS4encs_ C0-r WC41 Omer I i\LL,
<br /> Number of bv■q units _.- Nu-be,of �,�.
<br /> Craecw M Mar to a depth of 1 feet �t'1 - -----,---wales ta`t4 denth_-(jam
<br /> SEPVC TANK �`Type'Mrq �y p A Capabtr_- ._ No Compartments
<br /> PKG.TREATMENT PC C � Method of DAposaf
<br /> Datance to newest LVes _.--___-_ Foundbvon _. P,operry L ne—
<br /> LEACHING LINE Cl No IL length of Lys --
<br /> FILTER SED IA Dslance tc rWrest won-- iourdatKn_ --_ P,opeav Una _
<br /> —
<br /> " �
<br /> SEEPAGE PETS �PaC•ln __�_Sw-_-_ _,...- _-
<br /> SUMPS Lt Out►nce to noisiest Wee —_ Fo.rndaeon,.�-..._- P,openv line
<br /> t
<br /> DISPOSAL PONDS (l
<br /> I Itersoy CM IV rhat I have p,epa,ad 01!At idKatMn f -that ttN.r<N► w•1,:,e dote w o:cC,JYr+GE w,tr-Sar, %Oaqurn County o,d.nancoi.state Nws, and
<br /> rules and rag Aal,Wts of the San Cl ':ty
<br /> 110n,e Oamw CA I.Cenaed 1pent a s,gnttWe coo I+s Ihe tOhrw•nq 'I CMMfy(t'at M tt,a peAprr•unGe 4f the wept to,.Mich this pa,rml a issued.I sl.aa not
<br /> -raptor"V pwson,n such mennar a to t»omy w:.tect to wwsmeds compensator„laws of Cat,tom,m' Cnntractor a h,r,nq or sub Convactsnq signature
<br /> CMid,es the following -1 condi that to the pe•SprntynCe of the wO,y for whKr ih.a pt,rayl 4'00"d,1 Shad ernPICY P Wna a"I"t to wo'k-on's Contpanse•
<br /> tw.n taws of Coworhs_•.
<br /> The sppircant itwrss Int aft ad spactt - Contitiate d,awv.g on rep«u s1 /1
<br /> \a�,/ ` ��
<br /> Spited � �t•'�\�� T.W. —� 1 .aft{-
<br /> 1 ----- - ---- Date. 03
<br /> FOR 0EP*R1MCNT USE ONLY G
<br /> /.ppbcotlon Accepted by -Csi•-- -.- vats = ,SSC_ A..�_
<br /> �,�.. —--j
<br /> ev
<br /> Grotr Irtapactron by
<br /> aI Inapecton hY �`-1�/�•A� UMe
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<br /> AA6dnona,Cctn onts ---
<br /> Applicant - Return all copies to: San J.xquin Co mty Public dealtn y
<br /> Services, Eovirotmental Health Porsit/Secvicea
<br /> I1b01 E. Bal:eltoc Are., P 0 Iter 2009, Sticctna, CA 95201
<br /> { INID Af T DtJf AMOVNT Mf M'iTfG K ALC[rvfC fir DAT( 1fNMIi rip
<br /> 1 CAS«
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<br /> t«tirwv ,••. j�
<br /> �----- Z4 x'10--�(SS_j t•
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