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r ; AUG-25-03 08 :48 AM <br /> APPLICATION VOR P201T <br /> SAKI 3OAQUIN COUNTY PUBLIC HEALTH <br /> SERVICES <br /> ORIGINAL <br /> FNVIBOS+II�FNTAI. HEALTH DIVI _a��o <br /> 1801 p-OBBOX 2009,vE.ST(�STUN, CA 95201 <br /> i Y x <br /> (Complete in Triplicate) <br /> for a pvrmtt to construct wnd/Or install the verk hei4gegulaatiOrledof Sane <br /> Ayylicats.on is hereby made. Bea Jpaqulp Sa Joaquin <br /> Ordinance NO. 549 and 1662 and the Rules est <br /> application is made in cOmpliatiCe with Ban ,laariuia Caun+hY Joaquin County Public Health Services. Lo yi2e/AcrCrlfr,c <br /> Ctv <br /> Jeb AdAfa9S C116I Of <br /> Phonr+ <br /> V..!�i. <br /> —_ Addre94 � ~ <br /> t <br /> owner Name .g.}f.•2 phone <br /> #` L`� License No <br /> r�-" f 5grviea titeal <br /> Address r1 L �► //v J- - DeST'RIJCTION L-I ,R t <br /> Contract WELL REPLACEfvIENT l 1 t4pnstoritia well t7 <br /> TYPE pF WELL'j UMP NEW WELL C] OTHER Cl <br /> SYSTEM REPAIR, Cl PRpp L1NE __---- <br /> '-- pu;MP INSTALLATION Cl DISPOSAL FLO.-...-.�-- <br /> SEWffi LINES --__ PITSISUMPS <br /> DISTANCE TU OTHER WELL <br /> FOUNDATION <br /> NEAREST:'SEpTIC TANK ACRICULTLIAE WELL �_- .- - -- �� <br /> PROBLEM AREA CpIVSTRIJCTION SPECIFICATIONS <br /> ' TYPE OF WELL � -•---"J"T� _ pia, of Well e9inR �._,�.,..�--•� <br /> 4NTEND_€O uSE ---- <br /> Of Well �xtaVattpn— <br /> Cl Manteca <br /> I i Indus+nal C]+Dpen 9attam - 5pecHicHtiena <br /> [,! Ciraval Peek Type p1 Caeiny......_...._.----- Tvpe <br /> i.l Tracy of"Grow�._..---.�-�- <br /> [ I damestrnlPrivats I 1 Delta Depth of Gaut $eal ..-. .------- _ <br /> Pitblig I,l Other Tr ` <br /> I i �d9191n $UrfaCe Sisal Installed by�------ <br /> i l 1u+Uattgn , ,.. Ap1Nax, Depth P. -- State Work Dane <br /> K. -------._._ ._ <br /> Repeir WI Bane l.7 TVPs Of Pump 8ealint3 material E 9epth <br /> Well Destruction t7 Weil Diameter Filler Natarial A Depth is <br /> Depth pa <br /> available within 200 toot.) t <br /> jyp€ a0t: $EPT1C WL7RK- N€W INSTALLATION i t gEPAI AoOITIDN OESTRUCTICIN l i­Ift system rrriitteed i{ pit•+t sew <br /> Commercial-_ char r_... *�• I <br /> InstaNation will alive: Re dance ILIO <br /> Numbef of living units' Number rah Water table depth -----'i, <br /> Character Of soil to a depth of 3 fast: � No, Compartments -� <br /> Type/Mfg { Method Of p�sal <br /> SEPTIC TANK ' --»-- - <br /> - � <br /> PKG. TREATMENT PLT. Cl � Foundation__,_� , <br /> 4 Property Line <br /> Distance to nearest: Wellj%70 t - <br /> _ ' __ _ T tal longthlsizi <br /> LEACH)NG LINE No, & Lan@fh,o! lines - 10+ Property Line <br /> f Foundation----kre-�--- <br /> FILTER SEI? i-1 Distance to nearest. Well'.JD- <br /> I <br /> SEEPAGE P1T5 Depth <br /> Wall Foundation. . - <br /> SIJMPS 1.1 Distance to merest: <br /> M. t <br /> DISPC)SAL PONDS i 1 <br /> ' I hereby Certify that f have prepared Chita applicat+4n and Cha!the work will be done in aceardanae with San Joaquin county prdintlnCe9, State laW4, an <br /> rules and reoulations of the San Joaquin County <br /> Home Owner Or licensed h menne signature <br /> tobecomesub C011owing� "I tp WOrkmeT)Bdcornpen69+ily That in`on law@ 91 California," 1I oy Ct"not b c,to ork �n's foi@nletuae <br /> erripiov any parson such ns cuts act to workman's eompensa <br /> oertitiaa the 1+lilt?wing:"I C4rtify that in thtl Pat�prrhenCe of the work for which this parmit i4 iaaUetl,I cattail amplpy Pew i <br /> Tion hNe of CaNiarnia," <br /> The applicant t call for all us 'napaehons, Complldrawing On reverse aid <br /> aa e, ' <br /> . Dela: � T <br /> Signed X..._ .-. Title; <br /> j n FSR DEPARTMENT USE ONLY , <br /> Araa .._. ,._.. <br /> Applleation Accepted ted b <br /> t p y <br /> Final Inspection by , <br /> r Grout Inepectipn by �#lt[���^^ Det :1 / <br /> Additional COmmenta: <br /> Applicant - return all copxaa tat Saar Joa4u&A COuaty Public Health <br /> t Services, Raviroomental Health Permit/sery cam CA 95201 k ' <br /> 1601 E. HaztltOn Ave.. P 0 Box 2009, <br /> I AMOUNY RECEIYEp BY OATb <br /> C1UE <br /> PERMIT 1I <br /> FEE 1 <br /> AMOUNT REMftTE9.� CA$11 <br /> INFO <br /> Iii 11.21 Ipty 51 . <br /> to;1n �— <br />