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AP1•171 t . Al I UN 7 i N.101411'
<br />LAN JOAQUIN COUNTY PUIfLIC HEALTH :4:RVIChL
<br />EN litON MEN DIV14i ON
<br />P 0 BOX 2009, BTOCKTON, CA 05201
<br />
<br />09 4cits -3447
<br />EKMIT EXP1RE:iA IIAILIK0m DATE 1ABL
<br />(Complete in TriplIcKte)
<br />Apy:...cation to Terri'', made to Sc,, J,..4;uto Courty f,,r a ver,.,:t to Li on. t or notall tte work
<br />syyll:attoa e or.de to coeipllor.ce vitt Yar. JcAquto ,rdirAr,ce `,..Y • .4 tt.Z ind the Rules
<br />quto County Fttilt flesltri berYlcea
<br />Jute A041111141 Le/76 _ 6..r caste
<br />Connactes _.tirlt/2";46:/nr.<4.'t e St 2 .1,2 e _ (/•• sr 111::YY?'LL P"one
<br />:•(sTR07T.ON 4 Service Rol; (1
<br />Ronttorind Well n
<br />.SA; FLD _.--- PROP LINE
<br />PITS/SUMPS
<br />beret,. des ,r1t,r1.
<br />ALA itegulAtIon. .f Ocli
<br />flwrior's home A1.1-- ("1. 1:-)/11--" /-2 t: ;.(:••-•
<br />, -7177-•
<br />•
<br />Phone
<br />TYPE OF WELL./ Pi.•7/R Nifiv
<br />PUMP if,,STALLAT.ON ' so,Ti 4,a C.O.:,
<br />DISTANCE TO NEAREST SEPTIC TANK , %ES
<br />iOuNCATION Ai,,R,7.:)LTuRE
<br />+ ihev't d •
<br />, linudloon Tieolf, Eery,' S• : ,.•• • j
<br />Will Deatfuctson
<br />INTENDED USE
<br />Inchismai
<br />Domesoc/
<br />P"onc
<br />Papaw wort. Dona Dor:4 Type of Pomo H P Ii
<br />)1C Well 0,emetel 7.4e.it4 *Ate , 4 7..0 4.2 .
<br />°g ot riller Mate: ia: 6 I>ertr, f:A9/
<br />TYPE OF
<br />Qper,
<br />Cl (wee" Foca
<br />I I 'Antis
<br />amoB i em
<br />,
<br />CON.SIFIUC ' • 1
<br />-
<br />Cavl t
<br />!,,.ti et o
<br />0.. of Well Cas./42
<br />SOen•f•c•Rons
<br />.-- Type 00 Goat
<br />TYPE OF SEPTtC WORK Kik INSTAL 111110h MAIM ADDITIGNI itt,il woo, tooar, permolted .1 p..L.,.: eervee, .s
<br />with,rt 200 /eel I A3
<br />Insibilatitin will MONO COM/74 ,06i Gine/
<br />Nurnbar of trying units — Fiantoilir of Taimyr,.
<br />Cr•arecle, of owl to • awn of 3 feel _
<br />SEPT,C TANK
<br />PG TFIFA MENT
<br />0.stanceI., ,.•yelo
<br />LEACHING LINE
<br />FILTER fiED r."1 Doitani.io to ne e,et.
<br />SEEPAGE PITS I Doom Sd•
<br />SUMPS I
<br />DISPOSAL PONDS
<br /> r
<br />U.Stental to ne..•111 .V ."
<br />Mita table 0•00f1
<br />. Civic t, No Compartments
<br />Nielno4 of DIeboaal
<br />P ,../V4In, ohs
<br />p*,
<br />1, •1.8.
<br />P l'Arte LMe
<br />Li..
<br />I Kineby comfy 'ha I have 1te1.1-00 In.11 stip a• •I '0 •
<br />rust& VA regutiliOna Of Ole 5b , Jua:
<br />Morns owner Of I.tenald sow, I e.g •...'e et 're
<br />employ any Nilson .01 autb manner cu Le, a 1,
<br />CartIliell - I Cilrldy met in ins port
<br />1.0P. lOwl of California "
<br />In. epphcant^ t GAIT
<br />5,9,40 X
<br />Application Atc.pte0 by
<br />1 I A 44111 oil% tics Loom and
<br />gr. . • • I penr,,t i%TAM I Viol nu
<br />V I OI 114' 4,1 • • I Ad :I, ot s.t cu matting sliniokor
<br />, • • I •••„.0 s.,s tO wOisrnao Conluaris•
<br />Dela I 4/_
<br />4
<br />C7 -
<br />LY
<br />Ate*_ 11
<br />Ct..n ...visa 1..-Ct
<br />AL,OAAAL.' ';-2A SNL11111.11.0.A.L.
<br />f-OH DEPARTMENT USE
<br />c.l.k,) ,
<br />Pit Cl GrOut Inspection by —__________ Data Fos. Inspecttr, t,
<br />AOSitionaI Conifneroll ‘_)a
<br />LAN JL,P.‘4 1,IN ii UN' itUTIC HEALTII
<br />IIE.ALItt P.101 I TfSkli,I ct.s
<br />1.t,.1ti JoA•d OIN, 11,-4 UOU llelLTutr, A
<br />r .11 NI:
<br />A15
<br />44,11caot - coptee
<br />I P1 MM'! NO
<br />1
<br />-1—P 13 6' SP' oc-ti
<br />3S— O_C0C-w\ ,ScA-4rIGI
<br />ank-f2-1tt+ 61 re L711-
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