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Comp ea in Triplicat <br /> 5:. <br /> Apyllcatloa 1a bareby taade,t.o Bao Joaquin County for a petrolt to construct and/o natail the +tort herein deacrlbed. Ban t t' -. <br /> aptllsatioo Sa meads In et.Vllance with Baa Joaquin County Ordinance Ito. 51,9 artd I662 and the Ru:sa mad A46ulatlo11e of San �,• ,+ ' <br /> Joaquin County Fublle Health Serrlces. y'1 , <br /> ( !! Or 1t kV )r <br /> /�A !ti G tA1All r C a^'t City�TUCy�n/ i.ot 9t cs,Acrenge _� <br /> ,lob Add+att '4 <br /> J:JA,•�•N !'nrt'PCt; rir�l• 1,c- Ur C.lt r <br /> 5� $d tt3 STaCictati cr49�:1�1 <br /> (AT'r}CtilG G1°rM.Tat'1Y Add,afa --�f,..- L_- —_ Phon• _ .f <br /> &Agar's Noma_ / yt a�,: <br /> t-AYKrL.X ST. `,ZU� <br /> ti Ad.�ess <br /> U 7C K;ON C,4 9 �_License Phone <br /> Conlracttx `655 71•Z §` <br /> !t S � �... -� <br /> r TYPE OF wELLIPUMP: NEW FELL �~ WELL REPLACEMff,T r DESTRUCTION Ci Out of itorI a sfe11 Cl i( <br /> lbnitorlrts tle11 '%• <br /> PUMP,NSTALLATION Q SYSTE•MrA/,,PAIR C7 OTHFR ❑ 1 i E <br /> DISTANCE TO NEATEST. SEPTIC TANK 7 .� SEWER LINES ����q - DISPOSAL FLD.��� PROP. LINE - <br /> i FGUNDATIC l 7�O _ AGRICULTUNE WELL Lo-••_ OTHER WELL �O PITSISUMPS �A- <q <br /> _ r t.. <br /> INTENDED USE 'YPE OF WELL PROBLEM AREA CONSTRUCTION SP_CIFICATIONS It ; <br /> i ❑Open Bottom ❑ Manuca Dia,of Walt EKota-inn D+a.of Will Caning `� - <br /> n I rdaaaial c H- <br /> T e of Casing �vL Spac+lkit�ns� -----�—� ; !;. <br /> CornasliclPmeu Ll Gravel Pack n 714cY Yp gr--_ Type of G+ow Nir4Y 0"'Nir�-r l <br /> 1 I Pub„c a ltlog"` G Kell roo-7t'RrfL fl Data Depth al Grout Seal <br /> t n r-c7f-'Uri <br /> t'111iOatwn ..�Apima..Depth v^casrarn Suffice Saul Insts!ed by <br /> Repair Work Done U Typo of Purrtp H.P. Stale Work Done t _ <br /> Saaliaa Naiades i Depth ! <br /> Well Destrur6on Cl Well D'umem h <br /> Depth Hilar Material A Deyth <br /> f. <br /> { TYPE OF SEPTIC WORK: NEW kNS1ALLA TION I I REPAIRlADDi710N 1 I 6ESTfll1CT10N 1 I INa aepht sytrorn psrnrtted it puClic sawar q 1 <br /> B evadable within 200 foot.{ <br /> 'a Instaealk j+rri4 NM: Residence— Cllrru,tafcial_ Dlhaf y r„ <br /> N�Nwtsbar of kvw+g u,ita:.__ Number oT Itedroorns a h , <br /> } CIW&CtM Of Poll to a depth o.`S 1641: rna 11 <br /> SEPTIC TANK ❑ Tvpe!►Ifg Capacity R� s <br /> P1tG.TREATMENT?LT.11 IrTagpi sot <br /> Distance to neral: Walt Foutdation Protfni o f f([}!J�����5'� • ,: <br /> Six <br /> LEA;,141NG LINE Ll No.i Length of Iu,y _ - o� 1G}'" ,:•.f <br /> E .-AD n Distance to naa:afr. We" Foundsuon�� 41Wri`Ja,tY Lira <br /> f SEEPAGE PITS .1 Depth —Size - Numbar _ 'I <br /> SUMPS f.l Oulanca to(1,611181L WON <br /> FoVnOaUDn PrW+hy liM—_ t <br /> DISPOSAL PONDS L7 <br /> 1 — — t <br /> 1 hotel)-;cortity that I haw pispsred Ihfs eppticatlon anti that ine woes wiH be dons in a[C orosnca v+th San Joaquin County,a:d,nancas stale fetus,and t <br /> j gums arsd ragulahoru of the San JCaquin county <br /> 1 Horne owner or ksmai agani t ugneture canities the following:"1 cattily that in the posdorrrtance of the week lot v lieh this permit is seated,I ahaY int <br /> ! arr,ptey any pwaon in tuck rnanner Po to bacoma Wblatt to workmans componsnion IaWa of CalJorrria."Conl:3uol's hiri�p ar sub conlrauing 1.19nalure t <br /> . urtif4a the fokowing:"I Comfy 041 in the parlormanca of Ihs work tot%%hith this permit to sssusd.I shall amryluy perwna wG'•t t to workmsa'a Compania• r, .:• <br /> Bart tows of Cakfomlo." a f#A27 <br /> � f a 6 ft 7"y� =t'} <br /> The app=f) <br /> tl la all lrrq 'ha n Pts d(nving an tavaraa i,de. <br /> t <br /> sgn.d <br /> Title:c.4• r� .3 Dile: -3 <br /> FOR I)EPAliTMINT USE ONLY <br /> Data ' Area <br /> Appbutlon Accepted by <br /> i `` Data Finol inspection by _ Dau <br /> { Pie w afoul IrApactbn by i <br /> ll i <br />' Q <br /> Applicant - Return ■T1 roptee la: San Joaquin County Public Health Services 1/!{[J ifs A" <br /> A r 1 '•'.-�.' <br /> Rnvlronmental Hoalth P�rwlt JServteee <br /> yy 445, H Ssr. Jo►quln, P 0 Dox2009, Stkn, Ca 95201 <br /> FEE DUE AMOUNT ftEstITTEO K NECEWED tiv DATE PEtiI.uT N0. i.• c •-.••. <br /> 1 tsEV,vas lYI-' .aa�;;r•. <br /> t <br />