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PA r�a� <br /> APPLICATION FOR PfiR31I W <br /> SAN JOAQUIN COUNTY PUBLIC HEAL <br /> ENVIROiNYBNTAL HHALTR DIVZ <br /> 445 N SAN JOAQUIN, PHONE (209 0 <br /> P O BOX 2009, STOCKTON, CA <br /> MIRESIT <br /> (Complete in Triplicate <br /> Appliaauoa 1. Newby ode to Sm JeWuta CettetT for a peteft to eoNt,00t and/or LNt.JJ. the, work Hereto de.aribal. nil <br /> SM11oatlen Is W. is b lleana with Sao Jugulo Cowtty Ordinance Ro. 549 aM 1862 and the Rule. aYd R.MilatioN, of San <br /> JwrpUa warty Public Heap), S.rwioes. <br /> Joh Atldraa-_2Y' 2L / 7 <) /G1ty�/u /i ©Loi slu/Aereege /C <br /> Qwnnfn <br /> N. C" '172R'YL AAyche.ss7 .YMy/86 <br /> /5iW, License No. ���G Phona�� -J!C <br /> TYPE OF WELLIPUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Wnea wall R <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Nanitcri4 well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL fLO._— PROP. UNE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE Of WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll IMwkul ❑Opwt SONom ❑ Montan On, of Weh E.uwNn_ da.of Well CftkV <br /> ❑ Oxrepa/PM.te ❑&r Pa ❑ Trery Typ.off Casing Spncifip{tion{ <br /> 1'I AdAIc 1:1 GIN, fl DHta Depth of Grout Slid Typ.of Grout.. <br /> I I IRilwAn, —Apprw. Depth I I Eastern Sunw SW I..w by <br /> Rapes Wolk Dom Ll TYP{of" H.A. SUN Work Dore_ <br /> WO Desent tien ❑ Well OwMNw Sal.1n, Hlitarial i Depth 09 <br /> own Filler wtarlal R Depth <br /> TYPE OF SEPTIC WORK: NEW if pubic INSTALLA ION IV PAIRI DDITION DESTRUCTION (No septsystem P <br /> ic xmittad sowar a <br /> (/TS+R r[�i ylA�r was t r - ..Mwft.0h.2OD;r,1 i <br /> In.tri tion will wv: ReaidrtN C.nwn.reiN other � �f,.e e/d r�,ai ` 1c <br /> Numbs of Frvin f,unit{:-,Z— Number of <br /> CNnatN of sol W.depth.13 Mt: We.teba rapt. (� <br /> SEPTIC TANK (I TypOMlp pRiry ldna No.Cornp.rtm{ne 2— <br /> PHIS. <br /> -PHO. TREATMENT PLT.❑ EmePt Method of Dieponl p <br /> Owu nc.W heshwn B F rnhn on-- PropanY Lax <br /> LEACHING LINE Na. i La+pN of ams F - / 0 T'Plo wngthisita <br /> FILTER BED ❑ Donae W trash: Well Founclhon ��' yt_ Progny Une <br /> SEEPAGE PITS I I own Sin_ Number. <br /> SUMPS LI Distxtc.W tlaar'tll: WO Faah intan Pro many Ute <br /> DISPOSAL PONDS ❑ <br /> 1..eby nnily IN'I haw.Ptep.rad Iha gpIllbon.MMI thel Ise wwk wID N date w accordance with Son JNquIn count,wdlmnWa, {tax Nes{.NM <br /> 1.10.AN rpuletcn.01 the San JolgW. Cwnty <br /> Hanm owmr a IioMW.pmt's.gre:un wnilin dx foMwirtp: "I tulnity tMt in tM pdpmeetu o}tM vron for whit.NN petMt'r aausd, I.H,all not <br /> -10Wy arty P{non in-Kh teener m W becarrx wbf4ot ro woeman'.to npeNstim awn of CalHmral"Contal:Wi.N.,or wtrconlrmlap Npn{tur{ <br /> INS IN tovoenw"1 candy Nat in IN p.nar..of the work for which the pwnMA is ietxd,l aNM sorrow perepm wbMtt to wmktaan'•ton alus <br /> dol own of C.IHab..•• /� <br /> The• 11 far tw�k. ettwm. ca.,Pwe&..man meta.odd.! 0 3 <br /> Spred ?? Tope: <br /> FOR DEPARTMENT USE ONLY fSJUvOp cJ"( <br /> /p �,/ �,[/� <br /> Apppmtfon Mr:.ptadj by G '!(/ Dae "Afie <br /> m enOraut I bV Data— Fee;INP oeoh fN Dna <br /> v4G3- <br /> Addi lWtel r _r was a nar aG ctm / Cnr..��._.�__&,a,---JJi-,a,c--�-J�a�_ - <br /> Applicant - Return all aop.ee to: No Joeauin County Fnhllc Health R—icee �[Gf// <br /> Bavixomaoial Health Por � lalt/Sorwicae GGsv><r�c+� ' �'/ wsQao<w <br /> �l 445 M Sea Joaauia, P O So. R009, Stta, CA 95201CK ( az lr;rra a!/dl+ nrl/s <br /> Nq 0 W f0n AMP NT pUE AMOUNT REMITTED CASH REMOVED RY y OA gPEALI/ 'wo(. <br /> .ase=labs rr.e� 5.^ pd y0✓ L{ O✓ <br /> p1N 'f'(t�i WPS <br />