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<br /> APPLICATION FOR PRItN I T
<br /> SAN JOAQUIN COUNTY PUBLIC 11EALTr11 SF:1tV1(x:;
<br /> ENV111ONI111iNTAI, HEALT11 AIVISION
<br /> 1601 S. 11AZELTON AVE. . 1"HONE, (209)468-3420
<br /> P U 1303( 2009, STOCKT'ON, CA MoZol
<br /> V1=11 Pill !t )
<br /> (Complete in Triplicate)
<br /> Aypllcatlno is hereby swe to Sao Joaquin CotiYty for a permit to construct ani/or lr.etal: !:c n. f4 herein described. This
<br /> 4,011c4t1cm Is sw4e In co4llance With Ban Joagttn county [trdtrunct Mq. i4v enJ 1Fue •r..1 t:., ru,rs and Ae
<br /> ,10"uln County Public dtllrtiuna qC :an
<br /> ffeaith Services.
<br /> Job Addis%& J?
<br /> .�—
<br /> Ow1w's Name
<br /> Phone �
<br /> Contratla
<br /> TYPE OF WELL/PUMP
<br /> NEW WELL ,`rEtl 11{ ;ALL',1k f.T
<br /> l.'k S 11+�:'riUN�� Out of yervlce Well I_
<br /> PUMP INSTALLATION SYSTEM REPArH p)01111 Nonitoring well
<br /> DISTANCE TO NEARECT SEPTIC TANK _&4j_e_ SFV.ER Li%(S f)I,fF JyA1 t,l) PROP LINE
<br /> FOUNDATION ,.. -.__ .AC,RICULT{IgE WELL 01HER V.fLI _ _ PITS:SVMPS
<br /> INTENDED USE TYPE OF WEII. PROSIEMAPEA CONSTRUCtioN SPICIFICATr()r„ —
<br /> i 1 Ir1du►Ilost~ � t i Open 0ollom i r Ma•',eC.1 L,a of Weu E,crrrla,r,
<br /> Ihr u1 Well GVng
<br /> [t Dornazw Powste I t Gravel Pecik I i Trary 1,14 of Casino _ !;IWL,lr'
<br /> �dlions,
<br /> r PlrbkG .011im I Oeua UepFn ul L,rtlul Self [,pt of Gfuul
<br /> r I11,Uat.0" --Aplrrov Oeplh 1 . Easle,n 5wfr[e 5wal Ih►Inyd by - _
<br /> Rapa,r Work Done ❑ Type of Pump J�___ H P ___ _.._ _ 51410 V.wi U„r•e
<br /> WON Oestrucllon I 1 Wall D+amalm „. +ealir� Material i Del the ��:4t_- — --- - i_r, I ,+ r (f t
<br /> Deplh.��_'.}i,• �j filler Notarial L Depth _—_, __._.._� _ ~�
<br /> IYPE OF SEPTIC WORK ,NEW INSTALLATION 1 r HIPA,41,01,00I1`I0N . [ASIOltlC110N iN r jvpi, t.s1n•„permitted d p,a,I,c srwer AS J�
<br /> r.dryb.n At!,rn 2W furl I 1
<br /> Inalallatrdn wall So" Reordence Cofhrnerc,al Ulhor _ _ -'-- _ f•+. Y
<br /> Number of kvrrg unto Nwmbsr of bed,rwms _— c
<br /> Character of aoe to a depth of 3 Iml- _ `. _ __ .. .___ _ .. . :•.t.,, table depth
<br /> SEPTIC TANK ❑ TypelMtg Copac,lr _ r4a Cumpartments
<br /> PKG.TREATMENT PLT-Cl of D. 'y
<br /> sposal _
<br /> Uictoned Io nearest Well -- ruw.afa[•on Nop—•n. lint _.----- `
<br /> LEACHING LINE L1 No L Length of final -- -- _ _ _ lrrlol lanuu, rfo
<br /> ALTER FLED 11 Dra[anae to Muesl. Weil _ _ FOwndabun
<br /> SEEPAGE PITS I I Depth Site
<br /> SUMPS t., U•2,lancs 10 nearear Well __ Foundat,oh lh.nwY, L.— .—
<br /> DISPOSAL PONOS UI
<br /> I hereby Certify that I have p,rhaiud this 4pp6,a[,on and Sr.4t the r wk As Ur rt.n•. .n t. Lan,a r..l: own1v urdrhances,stale too".and
<br /> rules and regulations of I"San Joan.l,n County
<br /> imine owner or konse4 agenL's s,onatur*Lorerbes Inn f000nrnJ I ca-141 thos rr,the t J rr a nu— r„ nh,01 INS perms,s msood,1 aha@ not
<br /> amploy any person An tuts manner as 10 t,e401*10 sut.,eCt t.A01.rnan t tungra n.4ln.r,4ws:•f i.r=+,.r n.n �,-0,4.1r.,s h,nng of awb Cunti,oci g signature
<br /> corldies the tol$",ng'.••I certify that in Ine pertWmar,te u1 rho Aorr fur Ah,Gh lhrt I,rrrr,"1 s,u—,J r inn en ...pc-$Wnl swbltCl 10 r„orYman's C60llren4a
<br /> Ilon larva of Callfornie.'.
<br /> The applicant musi call for all ragwwred n'tprct,uns. Com Welt Ji4*ing a,rovers,►run J ,
<br /> ./I \ r J
<br /> r
<br /> Spned :r'-` +tea--• T•Ile —LL.LZ _. 1 L Grfa' 4f—
<br /> F DEPARTMENT USE ONLY
<br /> � L _ .. ._ .�-- / L- 11 c�7
<br /> Application Accepted by ki �• "'1'1Y — U4ta .._.�/l �1_ r. Arra -
<br /> r /
<br /> Pit or Grout Inspection by F"a1 Inspnct,en br -.'/1 Oste
<br /> Additional COn[n'arlts.
<br /> Applleant Return all coplea tui :;n:. Jon,uto Cuunty 1u1..' Health
<br /> ..erv:ces, }].�'ir.nacr.tw: health I'ermltJSnrvl:-.•s
<br /> 1UJ1 E. Ra.eitao Ayc.. Y J L.x 2GDy, 8twcxto:., -
<br /> rEE_- „ UNT OUf atrO JNT kf Mrt 71O f K+ NIC L,.LD B', I jArt, PFMMr1 kQ
<br /> t77a,NLr I 7Y
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