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APPLICATION <br /> so JQARUIN COUIM PUBLIC HBALTH SUVICBS <br /> 1XVIHEALTH DIVISION <br /> 445 B SAIF JQAQDIN, PHONX (209)468-3420 <br /> P O BOX 2009, STOW=, CA 95241 <br /> EMIT DATE IMM <br /> (Complete in Triplicate) <br /> snues"ea is hereon ame.tocompli Sea jospia county with sea jampia Cou Permit to <br /> 544 and IM and thsavor instau e Rules Legg Regulations or sanwork herein described. Thin <br /> yOlieatie� 3s •cede i.a ea�iiaaee <br /> joagais► ComttT Public swath Services. <br /> Job Address W City Stggkton - Lot site/Acrew <br /> (209) 9NI-A231 <br /> Ownsee Nanw Address 1324 W. Web= Ave_ Phone <br /> ConlfKW Address Z741 R&O, Mg&§&Q Licenso No., L4 70 Phone - 7 <br /> TFPM WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out oMoait " gel 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER L4 <br /> DISTANCE TO NEAREST: SEPTIC TANK �.... � SEWER LINES �- DISPOSAL FLD. PROP. UNE <br /> p FOUNDATION AGRICULTURE WELL OTHER WELL NTS/SUMPS <br /> IN"NDED USE TYPE OF WELL MMLIMM AREA CoNtTRUCTION SPECIFICATIONS 8 Soil HOdCivige <br /> 0 hrdust" ❑ open Soften en ❑ Man"WA Dia. of~Excavatkm Dim. of WAR Casing <br /> n Donrpie/Private 0&"Pack ©Tracy Type of Cuing Specifications <br /> I'1 Public n other n Delia Depth of Grout Seal Max,1Z.',..�. Types of Grou r- CCMWt/)er <br /> 1 !Inipshan —Approx. OWh I I Eastern SUd&cs Seal hwi&ed by,.,{u$torberc, & Stewart.,_Tstr_ <br /> Repair Work Dons L] Type of fhpnp H.P. Depth Stats Work Done_ <br /> WWI Destruction ❑ W84 Dbffww Beaune Iftsart" d <br /> Doh Til].etr I1ate:341. i1 Depth <br /> PE of WORK: NEW INSTALLATION I 1 REPAIR F TION I i W.TRUCTION I I iNo septic spwn psm*Nd it pubk saner is <br /> avaitsbls within=toes.) <br /> irwteNation ori serve: Residence_ CommerciW— 0*" <br /> Ot1wr. ..,_. <br /> Number of Thing units Number of befto a <br /> Charsaw of coif to a depth of 3 fast: Wow tsbb depth <br /> SEPTIC TANK 0 Type/Mfg - - Caaof<1►---�-- <br /> PKG. TREATIYgEMT PLT. <br /> Oistana to nureN: WON f5oWN10sion,_ .... PrrtpsrtyI WICCE V-ED <br /> ULAO MM LNIE ❑ No. a Length of Imes; Tom IargM►� <br /> FILTER SIED Q Distance bo nearest: We# Foundation��� � IN ODUNTY <br /> �Yr <br /> SEVAGE PITS I I Depth Sia, Number <br /> SUMPS Ll Distance to naanat: WsN Foundation Prowty 1 ins <br /> 00POiAL PONOS O <br /> I Manly tier*Mast 1 hra psepMsd this sppi AOM and ehd the work wR be Monts in aecord$nea With San JOslQWR aou+tlr ordinancae. $10110 laws,and <br /> orbs and reWdeft a of the San Joayvin County <br /> ►lance vioner or kw*W agent's iignawo o-1111--dor foNowing:"I certify.that the performance,of Ow wtwk for which Mia pennfl is issue!.I"cwt <br /> empley am paralar am in such aWwas to becorns sull00 to workmen's r anon Is"of Ca"nis."C a miring or wi}cpntrac11itq sive"N" <br /> cora 0 fttwom Ing "I cefft Matin the psrlomwnce of tlle'w"for vihich this pan*is hewed,I$"I ntope►aanti subject to warkam's compar'm <br /> LIAR bora of CaNfanb." <br /> The appfipM iwN far as re*mw imwtiotw..Comoro drawing on WMve we, <br /> Siprwd W Tlpe; 06112© MW WWI TT <br /> F � EPARTMENT USE O#ILY /�� <br /> Appi$rtbn Aeoepted by Date O t • Ane <br /> Pit or great bwpaaft by Date !anal Irw mdan by Does <br /> Additions!Commits: <br /> Applicant - Return all copies to: sea Joagaia County Public Sealth services <br /> x2fisasarntal Ilsalth Permit/services <br /> 445 It sae Joaquin, P O sox 9000, stkn, CA 95201 <br /> IIiPO AMpl1NT Ddi AlrMaUW RI MlfTEO CKAWAO D BY DATR hEltMf Aj . <br /> F CASH 11.W ts�t ta$V.l/• CTI a C71 NW <br /> ae a +P f i<ME292 Ca" , <br /> EH%M ` <br />