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<br /> bitAPPIA CATI ON FOR P611111 T
<br /> :,Py JOAGIUIN COUNTY PUt1IAC HEALTH SERVWES
<br /> ENVIRONMENTAL IihALTH DIVISION
<br /> P 0 BOX 2009, STOCKTON, CA 95201
<br /> (209) 458-3447
<br /> XjjAlT EXPIRES 1 YEAHYRQN-DAU ISSUM
<br /> (Complete In Triplicate)
<br /> Application to hereby fade to San Quin bounty for ape at t0 construct andler tnota:l tt:e work Aerein detcrioed. "`:•
<br /> application to woe to co%l:ance t.ith San Joaquln County Ordinance No. 949 and 1362 and the Rules and Regulations of San
<br /> Jooauin County Public Health Services.
<br /> Job Address 1� ?yam S,�R�=--a'� R D p C-ly ��._ LoIt bseiAcreye 4 Re_-'
<br /> Oyyltar'eNan+@ ST7iAi2Ts -611mgsR � L
<br /> Ao4ess CbfX .2.}i F_92 45x31 Phone `219-1�CtT_�-
<br /> Conl,acla_Z-_J-jZYL' F .lc�rYl�-_ ' '•st .7_��_.joEA��:PT A1'�-L,ce^te Nc Ad 34 ,,,74 PM., a_�jGt_37Tr
<br /> TYPE OF WELL/06%AP rtE.ti V.E, _. 'r+ELL AEP:ACEMENT OESTPUCTICN L-I Out cr Service W1. •• !
<br /> PUMP INS'ALL,ALON SYS'EM 11111114-111 : 0�►rEP 0 Monttorine Yell
<br /> OISTANCE TO NEAREST SEPTIC TANK SEWER LINES ____ DISPOSAL PLO ►PUP LINE
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS
<br /> INTENOED USE TVPE OF wftt_ P@ORIEfe PEA CONSTRUCTION SPECIFICATIONS
<br /> Ir dwanal Jw^ Bottom Ment.co D1@ 01 wM Isea.atlon_ -� Oo of WN C&SOV
<br /> U Connestc/Ptivato 0 Growo Pack Tracy Iypa of Cae•hQ-., Scoci►KaMNM
<br /> M PIIWK II Othe, Dena Depth o►Glout Sea Type of Groin
<br /> 0 Nr,gat.on __ Aptwoe Depth Ea n Surface Sea WslaNd by
<br /> I. r State WW% Dere_ ^�
<br /> Repan Work OOr+e u Type of OUI^O ---
<br /> Was Destruction 0 WN 0-smalet —� :+all►1{ tenial • L�pth
<br /> Depth—.�---_ _ /:/:er IYteria: • Ivpth _`- r��
<br /> TYPE Of SEPTIC WORT NEW INSTALLAttONNIPA.N ADDITION: Ut�THui-TQ1, N., "I-C &.item pe.m.rted d p..w.0 MyyM.a
<br /> $.a at.$".0-2M feel 1
<br /> Ina181181.00 Will NM Pee4ence _ Co,•Ime,c.a-L Otho• _-
<br /> Nunom of air,n0 un.te — Nu-tjo,of bad,00^+s_ t
<br /> Creracrer of mod to a depth of S tees _ SA_N_P Wats, taws depth
<br /> SEPTIC TANK e Typn:NIO C Pf-L Capacity- 0e1!__ No ComoatNnant.
<br /> aKG. TREATMENT PLT.[1 xr Method of D.epoaa'
<br /> D,stanco to newest Vitt �YS•�t FounOa+on_f;_ P,.cvrtt L.ne
<br /> LEACHING LINE l! No • Le„Oth of bnN Told-Nnolh.s.#a__a�
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<br /> FILTER BED ('1 U-star.ce to,.ea,aet Wan='T-It Fowr4at4n_�►-_.- ►,opaRy Line -/I'-/'
<br /> SEEPAGE PITS 11 Dog-it, -_.__-S.ee -- -- - --- N.,-t e, ---- 'I
<br /> SUMPS 1.' D•stance to naatesl Waa iown@at.un y---- __ P,owty L•ne
<br /> DISPOSAL PONOS 0 1
<br /> I ne,aby cart.fY that I naw P,608160 this appbc`ol a.{nJ Ihol the wo► w t'be du,*•n ICCO,JanCa 0-th San JOW-n c0vt lv ord•nences. uta 4-11 and
<br /> rules end repwlaNrns of the San Josou,n County
<br /> Horne owner or'Cenood agent a apna+u.a to-IJ-ea'M follow.,,Q 1 con-I,that.n tne 901100 o Ke 01 Ina-0,►to,+.h•eh thn pa,m,t n-ts.red. I aha,not
<br /> employ any pe,son In such manna,as to not ome subject to.wo.krhan a cWnponsel.on lewe of Caufoth.a Conuac to,s h.,.,g o,wD co^t,ac ang t1.gneWv
<br /> Conif.ee the h eow.ng 'I eendt Thal.n the pode,manCe at 1ne won for ft%,C%lk a patn+It H 00.90 1$%&"employ pe,60„a subject 10 ww►titan a eonrpM•aa
<br /> tion laws of C.Ilforn.a"
<br /> The applKanl trust caU Ip•N tolut,w e.etlactlons C Gate draenng on levers@$40
<br /> S.Qned L�-LZIL - T.tN --- Date
<br /> FOR DEPARTMENT USE ONLY I (`� ,sem►
<br /> Apobcst,On AccKled by*i!]. �A/1'V .----- Dalt11O -`-l��o A.. la L7 I
<br /> (/ ' -- 1 Dew
<br /> P,l or Growl Insplscv-0 'CT -.__.-�..__ Dale—_--_� Fine-Inapact•on by
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<br /> Add,t,onel Comments
<br /> Applicant - Peturn all Coyle@ to: SAN JOAQUIN COUNTY PUBLIC NNALTR SEAV1C199
<br /> IAtIR0hMLN1AL OKALTN DIVISION PZRVIT!StRVICKS
<br /> 445 N 1M JOAQUIN, P Ofjp-QX, 2(09. BSTUCKTUN, CA 05901
<br /> Oro
<br /> 0 Aupu- Ct.t_ r .rat cwt ��.r••r ; PtCtrvtOer� OAll rtaMn NO
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<br /> (,,1a.trfw /C v;`�'1
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