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APPLICATION FC PGISMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> SNVIRO?flLENTA.L HEALTH DIVISION S <br /> 445 N SAN JOAQUIN, PHONE (209)468-9420 -^ / <br /> P 0 UOX 200:x, STOCKTON, CA 95201 <br /> p�g�jm PxPIi?£9 1 Ys�AH YP'1= DATE ISS�p�I �.Ic g,� . /y.,� <br /> (Complete ir. Tripl icatel r r <br /> Ah1• <br /> AV911 on I. h.retry AAAI 10 E&b JoaRyln CO: ty for , Tum It to corvtru t .,,d/.l S69e11nd tM11Ru1e11 vork hapde RANlatlon. of San <br /> Appll eatloe 1. 11enN11althl-Cc n� Ran Jo.$uln County OrdlMcc. Ilo. 5 9 <br /> Joyuie CtRup t Sl ae/Atre.Se <br /> JM Addrew � , <br /> �/[" � �j � .4!/71.`29 vhoM <br /> OY S NNM`. CV[1O, (,�,�y�/�- A • w t5/t�r[ C����(//� <br /> N`/.�N1-LrIIOne <br /> Addre[t L�censt N <br /> Cont/atl Ct WELL gFptACEMFNT (I DESTRUCTION ❑ Out of /.rvle. all ❑ <br /> NEW WELL OTNER O [Lo.'1 wr1nS W11 <br /> TYPE OFA SYSTEM REPAIR O <br /> PUMP INSTALLATION :) DISPOSAL FLO— PROP. LINA <br /> SEWER LINES ?[SONES <br /> DISTANCE.70 NEAREST: SEPTIC TANK ---- AGRICULTURE WELL OTHER WELL <br /> INTENOED USE TYPE OP WELL M <br /> AREA CONSTRUCTION SP [ S Dle. of Wall ca" <br /> .CaY.h0l <br /> (l lyduOr'el O Open ROtIOm O Menl11ca TVM of Gu _ - Spaulrotnrl. <br /> !1 DoRNeICIPrrr11ta Ll G,W011w PNk LI TSG DepR of Groul 4u1 ^_ Type d Grout .�' <br /> I1 Omer /-'''r(DPI¢e O <br /> I'I PudN $yrlau$11111 In.taMd M <br /> Inh[111ion O.. D11DIh I fn11tam State Work DOM_ <br /> TVC of P0:1 N P. <br /> n,,Ae Wc,k DP,r— B11Al1 ry{ WNe1a1 \ 99th <br /> --- <br /> Wall Dutruclow ❑ Wall DNRIeta+ _ Piller we-Arial E Depth <br /> Depth mH.d if arC <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I OE57RUCTION eV'�ble. ��tpt 1 pI <br /> IM1Wtion vdN '. <br /> Rwkerr.e-^ CwtYnwceN__ <br /> IMMDIMr-_ <br /> Number of k." Number of bodroom11_-.-- WAIN table depth_ <br /> Cnww,.o/a01 to•depth Of D Net: Cap11NtY No. CwmPe-Ann <br /> SEPTIC TANK ❑ Type/Mfg _,_----- M.thod of 04PoMI <br /> PKG,TREATMENT PLT.❑ Found11lbn Propany I- I <br /> ObtNlu to MNxt: W11x —� <br /> No a r+ of lirW Total INgth/114[11__ G <br /> LEACHING LINE O FpunOatgn Prop11M I" U <br /> FILTER RED ❑ Distance to rtes,ta: We, <br /> _S'uR_-_ Number _ Ftp <br /> SEEPAGE PITS I ' Depth ,," t`V <br /> SUMPS <br /> .1 Dbtance to rwarwt: Well FouM.non___— Pr Line <br /> DISPOSAL PONDS_I .,at.leYr11, and [ <br /> 1 MrabY Ca H. IMI..''..p'.Mr.d In'a eDPI't aidl and tn.t tM wOri w+ll Irl done In.000r Olncl M+In$an JoaOuin COVnIY OrtlrMn<11t, <br /> rVNA ant!"gNAmt.of IM son Joel.- Count)MNr11 <br /> NOale b.Y'r,er w xCaIN110.g11n1'P pnNuro al,0111 the 101I.-lo. "1 canny IMr In IM peAOrm.nO OI iM won for weicn tor•parml M ruV.d.I Agl not <br /> 11rtlpbY MY pwson M 11uC11 Il", <br /> n f PN10rm IViM�Of�M owOrMo OAwTKhh thu pNMttlon n N 11d of iln.Nll 11mpl0Y person.11rVhMCl lo�worktrNn�CbtMenM. <br /> 'wffm 1M foso n g: <br /> ['ren lavas M Camon'" <br /> TM Ppo[rc t cM ai noN d A^ C[yR�n.COmplere drawing ap,L�Y'me ads <br /> r /[rJor /� <br /> Title Date <br /> grL- -s.. da : / J <br /> SMd FifYilf . C�.•�s.a <br /> VR DEPARTMENT USE ONLY dt ,L <br /> Data Alle, <br /> ApMNNbn Accepted by -�ti1ri��-�=�� - <br /> Data__ FIMI In.pecdon oY <br /> ht� Dm L <br /> Ph w Orbe Irutp.ctlarl a'/ -� <br /> Additional ComrMnla9009, Nt: - <br /> Appllc.nt - Return all cODle+ too Knvl ronerent 1'Healt�Derwl t/d...too <br /> p O Novl<ea UDS <br /> Hp N RAe .IoaOutn, r[ ., CA 95201 <br /> f[! AMOUNT bellH5��n <br /> lD■Y DAT[ eTRMrt NONIDCASH[07oL _ lL-�I-`li 97 - 3925 <br />