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I t . <br /> J., +, COLTN'1"f YUCSLIC HFAL1'Il :iTsflY1C%S <br /> „ti sOAQUT.' <br /> • k_rTv;}tOrluxl+•I'Af_ r�;A1,T63 a; 14 <br /> ON <br /> P U F30X 2000, S.jV-K'1'()tj, CAf 2.01 <br /> (209) 168-3447 <br /> (Conipleto SU TrlpllGate) <br /> r Ir <br /> § Appltc►t100 1s hcrc�y c.:o Sac Joaoulc County <br /> for a I�er.:lt fi cuna l:'>:ct aO1P,62aa:utt:•cl lca F•rSr lrgVIAILio IA Or b"Oe <br /> Syncs vI . 'Sea j,:juln ioua 4y OrGSr.a pc< NO. 1RS' <br /> T applic.tloD Is rade in tc�w <br /> JO�ravSn Cwacy Iv911c Yaa1RS 6sr�'fcer. may}^T //J�� Let 31te/lcre.dc - <br /> Job Addr4sa <br /> I srr S,' L PT.Oru <br /> ,fi 7 AJD Ca�lt1 � ruins ,Tt �Sr�r Sz 74 Sr <br /> p rwt't Narn4 <br /> 'S7-G0:7LJ P•,OM x{16 <br /> 4 / l 7 Addrtll 112?S Sw^r��('otyC;rc e 7 r <br /> rcn[rlcl t;E�'rwEzL ❑ 0aSrrYico Nell G <br /> - wELL ftEPACEMENI oFSTRtCT30N <br /> OTHER <br /> TYPE OF wELLIPU hip, r, SYSTIEM REPAIR 0 <br /> ,! yUMp INSTALLATION `�, pISPOStiL Ft0• PROP.LINE r <br /> S£�'JEft LIKES PITSISUMPS <br /> DISTANCE TO 1+'EAREST: SEPTIC 'fANK �-�— I OTHER WELL <br /> FOUHOATION �^ <br /> AGRICULTURE WELL ---- —^ <br /> TYPE OF WELL PROBLEM AREA COwSTRUCYron SDEEIFICATIONS 0;4,of wall Clrsl119 <br /> ------ <br /> j'r INTENDED _—-- �"s' vcl 04 Of will E.clvrs.On.^_���- <br /> 0 Op4n 13010M (3 Mlnleca Sp4cd car om <br /> 4?Industrial Type Cl Cain: Pvc r <br /> Q Tracy Typl of Grovt <br /> o0maat ClPrivita C1 4rara Pic'. - oy &nfo.+tto <br /> la OIMr <br /> ❑ Delta <br /> O4plh of Grout SaaL <br /> j la Puo�•C $vrfaca Seal Inttaned by <br /> U IrnUJlgn ADVo.. DeDIK 17 Eatlaan Stas.work 00" . <br /> H.P- -�-��J M1� I <br /> Repair Wort DO'" U ''lYg o1 Pump ;7 r--- � 1 �trria i DtPtt <br /> E r. <br /> will Dewuclion �• w411 OiirniteN 1 - :... <br /> 7 T111arr � <br /> 1� peh mttad"el pl ale uv�r u <br /> Depth <br /> TYPE OF >,'lORK. <br /> NEW 1r451ALLATION 1] REPAIRlAOOITIOr1 Lt OF5TRUCTIOH J ,rt'a oAl-1�ne200 11&41.1 <br /> will varve: Rosid4nce_� Comn.art:;O�-- Other <br /> f `InISIllI1K,n �.^`Viler Ubta daDth <br /> m <br /> Nabhf Of living unili:.�,-.� <br /> livr"b" 0f bedrooms <br /> Chassc Lar of soil 10 a loath of 7 fel: No.C0monnwnr= ---�— <br /> t ' SEPTIC TANK 0 rywl"f: FAathod of Di' ca <br /> PKG. TREATMEN i PLT.C1 Foundation PloPa ll L r& <br /> (lasance to nearest: Weer <br /> j. Total tenglh/s is r <br /> LEACHING LINE C1 No. b Length Of l.nat P1064rTY Lira - I <br /> FILTER BED naarail: Wdt FOvndlfOn <br /> ' f.) out+nce <br /> Numb4. <br /> SEEPAGE PITS If E1epth <br /> Lina �-- <br /> .—�"- Fowdal,on�r�-- P+opOrTY <br /> '-sumps Ll 0413MA tO r"rert: SYeR <br /> DISPOSAL PONDS 1 I'll <br /> I Mreby Cert,ly ihJ11 hi"O•IDeled this appliUt�On Inn!M! the <br /> w01►w.t1 ba done in IC(G•g.l^Ce with San <br /> wc kpf0+IiNlith ttcounty <br /> SOperm.t Ct"lurrii 1"to no <br /> .uldi and iaguIS60nl Of tha San Joaquin C";'11 n "I terlity this in the parlo—anca ClM <br /> ' KOMI owner or 1.nntad a?t'nr'a t'9^&lute cart dye the 1010+x` g ^CO.•111 <br /> 4 CLOP s hir.n:or tvPc 1krra n'1 c IrgniNu <br /> lms sable , tr.a w01t lo,�'niah this porTit,i levered.I iryll employ p4rsona IVbteCi ID wgrk fhiri t CDrr-0entl' <br /> employ any p.Ir1On in loch tnanr.ar as t0 pacoma Wb,eU t0 w0'kmin t cOm@0at31�Gn Saws DI Ca:�Orr . <br /> cenifiel th4 101LOwing:-I car6fy that in tM Da <br /> _lion Uyn of Uilorn4." <br /> ' Tho spplIcAnt Wsl Call!arM roqu"A!l,hlpe Lor.s. CO.mpeia drawn:on reverse side. <br /> .,� 011e: �....�---• <br /> 3q�d <br /> roll perARTr,ItHT u5F ONLY . <br /> E-. Ara& <br /> pale <br /> _4444..... ....... <br /> .. 4444.. 4444 ..... ...... 4444... 4444. . . . .......... .... 4444 .. <br /> a.pptcsuon Accaote4 by �f pita <br /> Dau Finat Inlpaction by _c-- <br /> a.,4it 0. Oroul Inspection by . <br /> Ionil Comn-AMC <br /> Rat + a ta: SIN JOAgUIN COUNTY PUBLIC HXALT11 SERVICES <br /> Pa11Cu: acorn a l Copia CICYL, CA P5201 <br /> tl6ALTH OIVISl0.'I PE"IT/sERVIC" <br /> S10 N SAS JOAgU1N, P O AII7L 2009, STUC <br /> uif7E0F <br /> r RtLilvly ay -t : <br /> Ftc aa10,)r.i OU( kMrtp,!RE � <br />