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Boomr <br /> % p. <br /> it <br /> t- , <br /> � <br /> I Y J, J� _ h S S,r . t _ <br /> J't� ` 4 <br /> L Ewe- t"siy.~ j', 3� <br />/ -��L�- <br /> I <br /> APPLICATION FOR PERMIT <br /> r-rt-: P• ti�� SAN JOAQUIJI COUNTY PUBLIC HEALTH SSFk►'ICES <br /> ENVIrROPMENTAL ILEALTU DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> -: (209) 468-3447 <br /> naT;j 7, S37� <br /> by <br /> (Complete in Triplicate <br /> IApplication is hereby de to Sea 'oaquin Count+ for a p.rvot to cinstruct and/or iratal.l the work berein dean toed Thisma <br /> ayylleatloo 1■ rade in entgliance vlth Elver Joaquin County Ordinance No 5L9 and 1$62 arA the yule■ and Regulation. o' own <br /> Joequin County Pukllc Healtb Services <br /> ,*b Add,. 39 r hle� �n_ <br /> C,tY Lot Elite/Acreage <br /> X1.1-�i rajry�1 N-,,,. AOdrtsa Alaf {J 3 <br /> _ Phone <br /> Owners 4BevFAcgArST C <AI <br /> � ` Xp _ P�I�T'S-l3�2G Gh �O+ �Licrrst no 1608pZ Mm <br /> .tr r` _ IattoryPfTLi�11 �, LOff#CT�� Addicts , <br /> y f <br /> r T1 Ps DF WLLL/PiJrdIP NtW WELL WELC�RfF FCEMENT n 'DESTRUCTION 0 Wt et Dervfe• Ve11 <br /> ^��`v s'c PUMA INSTALLAilON SYSTEry PEPAiR C OTHER O slooStgrlrlg cell t! + <br /> ?DISTAI.C_E TO Nf.AREST SEPTIC TANK SfwER LINES `— DiSP05AL fid _r PROP LINE <br /> FOUNDATION AGRICULTUmE WELL OTHER WELLJ!121' PITS-/SUMPS41 ` <br /> INTENDED US6 TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS to ' <br /> j1 r. Ll lr,ds+►er al O Open Bottom ❑ I.+a.+tru Oa of-Well f.c+vrl,on pas of Wat Cerin <br /> 4.�tT JAI- wYs j <br /> [}OorrreprclPnvare- C1 Gravel Pack 0 TrecY 'Yt4 of C*stny 11C Saeulicsoons <br /> E ,f 41,"� s '_p P/IbbC pf-,(lthw 0 Dells DIP h of Grout Seal -.�� TyPa of Grou s <br /> ��Aopros D>tpt.r C fastern Surface Seal Installed W 1�CArese�C <br /> Aspetr Work Done f] Type cl Pump fit- H P ^' State Work Done <br /> v t,F 8c 31 ►4twri&I a Deyth <br /> Woo clbn L3 Wed Dfameur <br />' r rot ^F, r-;'r H►m'al p �' l p.olh r Tiller Katerial A Depth ACrSr^ <br /> a�ye \ t <br /> '�'�Lj " .`'t r-+• ,;,_TYPE OF SEPTIC WOHi'- NEW INSTAL 0 HEPAIRIADDIrION M DESTAUre tON G INo arphc sYstam 00~10d 11!'•rbirc sewer u <br /> _ ^ available w,rrun 200 feel 1 F �� <br /> ` r t <br /> i�J 7t� ; ' 'c :_'rte Lnauzsr n w+B verve Revdame____ Com+rernat_ Other 1 3 <br /> Num6ar of i►+++p ttnru lumbo of bodfUGrra_. <br /> Water table dapth <br /> -Character of tat to a dap h')1 3 4111. a <br /> iEF'7iC TANK 0 TypelAAfp_� ,rrl lutY filo Cat+panmants <br /> PKG TREAIMENT PLT C1 / _ , s lerlwd Of Diapoaal 7 <br /> Distance tv nearest WeIE urdnan Pwparty Lln� t y <br /> LEACHINGS LINE 0 No 6 Length of lines _ Tolol lenylh/sat (; i <br /> i lt� x ,r�'t' Jw lti FILTEA�DED - 17 Dmunca to naslcrt Weft Fcundat,on Progeny LLse \ <br /> tTSEfPAGE PITS 11 D*p1h S Numbs t <br /> �SUI4tf$ ;° = LI D,s+anu to n►afect ed Founder on Props Llra u <br /> Yh4�ra/hw'�T F <br /> DISPOSAL POf�s75 L7 y <br /> x^ e. ' <br />-`-I `I henstry certify that'have prepared Ihrs spPIkJ1,an and Ihal IM v,ork will be done rn accordance with San Joaquin county ortl,r+nus state laws and .. <br /> rvhr and fagjjlg orx of the Son Jo►auin Couwq a <br /> Boma pvYn,Cr w beunsad 294Mt ponstura crud is the lcdov-Pp i canny Thar in the Performance of the worA lot which this parmlt Is issued I shell net <br /> amDloy a'tY W*$om in rug'mA^rw of to baso no avbtect Ia wo kman s campenisuon Saws of Caabrrua Contractor'$hwng or*vt>-contracting agnafule <br /> etnO t the la"WinQ I cerilfy that in Iha perfcrmance of the work for wh ch this perms is+saved I snail arnploy perrQns suDiaei to workman s compensa r l <br /> ss"� z itis a�Iipn lcws of Cwlfaraa" L <br /> rG- ^ <br /> SAS Wa+k:�� r;� TM appflurx I for ail r ad ItoactDive ComF;ate drawing on mrru <br /> SyJ�� <br /> ned GC- Tnie Data <br /> FOR DEPARTMENT USE ONLYzi7 a t <br /> Atceared by 1 r t Dale A / <br /> nspaetbn � Da[R <br /> Ph a Urlwl Ir,apection by Otte Fins°I <br /> r Addhlonaf Co+rxna^tt `� Y <br /> +t, <br /> STs li"1� -ys, `,ti •Jc �Agplleut - Xsturn all eorPiee t0l SAN JOAQUIN OOJMCT PUBLIC HRALTH S RVICES <br /> Lr <br /> HT <br /> tj _ .•"F� V„ EHVIAOMWZAL NZALTH DIVIDION rM)1/51MyICS3 <br /> e45 M SAH JOAQUIN, P O DOX 2009, 3TUCK:ON. CA 95701 <br /> lNfO, AMOUNT DUE A++tOUNT REI.+iT�RP CAS>i RECO'ED DY LATE F[AMFT NO <br /> tl� <br /> I.> <br /> EK If ji <br /> i :''Y• � �� ...r.-- �>. ,_� _lei..._ .,..-.....,-....., -W�i.w-2�.r.r �...n :.1cti�1'�." l+�^ � <br /> v. <br /> -b <br />