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Q f-t ' <br /> SAA .OAQVI2i COMM PUBLIC HSALTE .aSB�' (� �J <br /> EZ7' 1RONl1 m—L.LL Tm"T= DI VI S I ON'- <br /> 445 3T SAN JQAQUIIr, PSQffE (2D9)46t-'S <br /> P 0 B01 20D9 , S7VC=,Oh, Ce A_%W .'k <br /> (Complez.e in T:iplic$ e!) t v Tz <br /> ApPlleatloo is brmw ande to ban Joaquin+ eaumty So- a peraelt to ccostrucT +ad/a, l=TAII Ube vQrIL berth: eescribeG :mit <br /> LpplieAticc is made is ttsr+limacre v:th ban Joaquin cou^.ty ordizamce 10 514 amt 184 end the Rules atst hegulAticas a' Sas <br /> JttK"t County Public SralS.Eubtrt'lves <br /> Job A,,,, a �'S'CaST !7 at`et r c4v Cn7-S% To++ Loti Sisc/At rhe l� eu r-4*_ <br /> Owner a lwrrr.Q+oet m LAS f; Prtdu.cTs- Ca c�.Lll O W%8 $vb G de k d <br /> If C [ Adpreu CtZ *� +� �w►kovl G am/ p rr9I1 <br /> COnirdCtor C+r�S FYer'2,DK S..F dr ss y? ^.r lr, r--C C�� rPhOnt�47)nse M <br /> TYPE OF WELLIPUMP -NE",WELL WELL REPLACEMENT n DESTRUCTION ❑ Du: a: berviee Ye:1 ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ MoaiLaritts Well .� <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES 6b-."— DISPOSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Inpustnal ❑ Own Bottom ❑ Mantepa Drs o' Wei Excavation ZL bra of Well Cason � .v <br /> Dtxrtestre rvatrJ ❑ Grave+ Pack ❑ Tracy Type of Cas+np S4� yD C Screert►ritroru <br /> I . Prtbl,c Rpi„roof the, �hu .+ <br /> M D►Ita Depth of Grout 5saf Yps o' Grtw���Ceo`1--7'- <br /> I I krrpairon � �1 ppro>< D►Dlh I I Eastern Sur4cs Seal Inst*Ued by c� n,+ Sr✓tJr 3 -r,4 <br /> R►Oau Work Dome U Type of Furrw H P Stats Wort:Pons lr.11 -.-r%.!1 <br /> W" Drmuetioe, D Weil Drarnat &&Ll nE lor.teria: 1 Deptt .ti,rr �t�e.,i oLQI T <br /> Dsoth �T 7"_lle l6at.e-1a..1 IL Depthito in I <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDtTION ( I DESTRUCTION I I (No sepnc system p►rrnmea t1 pudic smvmr to <br /> warbBla "thin 270 Ise, I <br /> Instbutsi n V470 se" Rtros+derice_ Cornmerc►al. Other <br /> Nurnlw of "rip urtrts Number of bedraomt <br /> Charattsr of " to a arapTn of 3 fw Wate� r <br /> SEPTIC TANK ❑ Type/Mtg Capacrty No <br /> PKG. TREATMENT PLT ❑ Met o',pl�pgLAI <br /> Desiance to rturer Wel Foundstror Property Luw f��1 i11 L T-0,23 <br /> r I r <br /> LEACHING LINE Cl No d Length of lomat Total bngin/site = , I' L I h <br /> FILTER SED ❑ Dist►nca to row&SL Wstl 1`oun"tron Pr +I I <br /> OD►rtt' Line <br /> SEEPAGE PITS 11 Depth Six@ Numowl <br /> SUMPS LS Destarxe to rewrs. Wall Founaatron Property Late <br /> DISPOSAL PONDS ❑ <br /> 1 heretrr cwrtrty Thal I have Ix►paroc Iron bl>v4cJtrph anC Thal the worn, vnl be cone ra aCCoroonae with San-soaourn county oroinanCOL stats 4Wi anG <br /> ruMt &nt r►pulatron& of Ind San.1or.qurn Ca�usLy <br /> F{Cdl ov"nal Or I.Cans►C ap►rit a-phatun Ca+uf.►t Inc 1060v^ng I Cartr1Y Iha in the p►rlormanea 01 The work for Wh.Ch This permit n asu►G t "11 ml <br /> ►fnpioy any oo.-aon rr,w4Ach rrwrwwr at to b_Orn+ aut4oc, to wortmar t comperudiscin taws Of Calrsorraa Conlracmr s hrrmp Oi sup-Contracrosp srpnature <br /> c►rtrhe4 Tim Iaao.wtq 'I Cary that&n tM& perlo'r""s of IM wpr►lot rvruch Trus p►rrrrl is nau►c I Arrau amptoY Oer <br /> txm WWI 0 CalifOmUA wmt suDteet to wpetman s Cperyp►rtaa <br /> The aDOl.ean' rrreJa ass }a ar r►our� rr�strwu ComWets orrwuiC art rrwrae s,ps <br /> w el '�— <br /> S ne8 I Talc Date <br /> �R DEPARTMENT USE ONLY _ <br /> Applrut.on AcesgtwC Dy E `' I Dots Ars& <br /> Pn or Grow Inaowet.on Dy Date Fina Inspectoon by Data <br /> ddn,onal Commirontsb 5 i C �'�C I' �c�' {fes, C--DS �►lc -� �•�,-,, -,-;� <br /> Appll un; - hclu-c all cople6 TC Sar .)o&gLic CounTr Public bealtt SerliceE <br /> t Earl-oatnee1T.a? healtt Para,./5err1cea <br /> _ <br /> 445 h Sac 3oaquic p 0 box 200F Stkc CA 85205 <br /> / INFO AMDiANT Du[ ' AMOUh', REMITTED CASH I RECEIVED ll ' DATE PERttt'I ND <br /> i rr 1444 I r1eY r r s u j I/ i1 y <br />