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APPLICATION FOR MW I T POW- <br /> SAN .JOAQUIN COUlit :PUBtIC HALTS SSRVICSS <br /> j. RNVIRONYTTAls,: ALTH. DIVISION <br /> 05N SAN . OAQUN� pBON$ (209} 65 °342a �} , j �+ <br /> p 0 1301 zoa i 5��k, ;.CA 65261 y <br /> Ir!" r r rel} <br /> (Codwlete� in Triplicate) <br /> Application is hereby life to Bang JoaquDttaty fOr a pbtRdi� do ill c c .;6 . <br /> onetruet atrfl/nri irlstalf the work ereiTi' iiiii61bed. This <br /> application ii nada in da"W'liabeo'with 8""Joequi County.Ordittance Nb.;-549 and 1662 algid'the.Roles and RelittUtittna O! Sats <br /> urn County Public Selslth flletrvie*r: <br /> :x <br /> r),bAddrsae <br /> Ci V_ <br /> Site/Acredge <br /> i <br /> 'V <br /> Owner's Name t4, Address r" `�` Phono <br /> �Cy"_Pf <br /> , T _Llcense Nd: t Phone- <br /> OF WELL/PUMP: NEW.WELL ❑ W@LL REPLACEMENT C7 DESTRUCTION 1 Out or Service wall ri <br /> PUMP INSTALLATION CO. 5YSTEiiA REPAIR ❑ r 'OTHER C3 ,i' '1rollitoriog well ❑ <br /> DISTANCE TO NEAREST: SEIPTIC TANK -SEWER LINES DISPOSAL ft ., = PR00LINEt`,,, <br /> FOUNDATION AGAICULtURE WtCL- ... . OTHER WELL_ , , > PITSAUMP$' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA :-CONSTRUCTION SPECIFICATI .ONS +� P, <br /> — - <br /> E7 Industria! „ ❑ Open Bottom ,,.C] Manteca `;.' Dta; of Wefl Eilcs4irlitln ., ? , 'oia:of Welt Ott sing . <br /> Cl Domasek/Private 0 Grave! Pack* d Tracy Type Of Casing__--� .__-- Sp6tiflcati6ns" <br /> 11Public I 1 Other 'f l Datta Depth of Grbut Ssa! '' ` ' ypw'pf G�tlut <br /> I I Irrigation __ Approx. Depth I I Eastern Surface Soul Installed by <br /> Repair Work Done . U Type of Pump: _ H.P. State Work Done <br /> Woo Destruction D ` WNt Distroter`.' lleal:ins 11.torial E Depth <br /> Depth -- _ _ t"iller List iio1 a'nth E <br /> TYPE'OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I -DESTRUCTION SNo septic system perrniHod it public sewer is <br /> t s . .. available Within 200 feet t <br /> Installation will serve. Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of roil to a depth at 3 feet: Watoi table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity ,` Na f*ompartmeinh - <br /> PKG. TREATMENT PLT.0 1' ' , N4ethod Of Dislibr. .t V ' <br /> Disiare to Merest: Well _ FoundationLEACH <br /> f <br /> f+LTERlBED!NE C1 Distance roth of Imes ;ka. T01t11 length/site <br /> n0 <br /> niaraat. Foundation Property Line <br /> SEEPAGE PITS <br /> it bepth " _Size IT Number <br /> SUMPS L'1 bistance to nserast� Well Property LIt►e u, ` <br /> DISPOSAL PONDS D <br /> I hereby comity that l have prepared this application and that the work will be don*in accordancewith San Joagiiln county ortlihAriCa,State laws, and <br /> rules and repuisliDna of.the San Joaquin Cotmty �, t , <br /> Home owner or licensed agent's iipnsture oenifles the following: l certify tht t in the performance of the lPif&which this`per;4ls Wusd.I shah not <br /> employ any person in such manner■s to become subject to workman's compensation laws of California, contractor`hiriA0 tlf su6cbnttactino signature <br /> comifies the fbNOwfrap:1-90010y shall OMMOV persont aubjeet-to wtrorkniin'a compenss <br /> rtlfy that In the performance of Lilo work for which this permit is issued,I <br /> tion laws of Crlllomia" <br /> applicant must.yaN for all uk in tions. Complete drawing on reverse side. ��yy <br /> Signed Tido: , . Date: rlo . .rf�T�^w. la� <br /> .._; _ <br /> R f)9PAA1 <br /> ISE <br /> oNLV <br /> Application ACCsoted by <br /> Ph or Grout Inspoellon bye �. Date Final Inspection by =i: `Date ✓ <br /> Additional Comments: <br /> Applicant - Return all copiee-to: ban Joaquin Courity�Puhile Health Se>rvibert <br /> a Sovironmental Health Permit/Servicers <br /> 445 H San Joaquin-; P o no* 2009, Stkn•, OA 95201 <br /> EEE AMOUNT DUE AMOUNT AEMITTE6 flt'CEIVE6 0Y J DATE pERM1T'N0. <br /> INFO CASH <br /> ♦ EN11-N IIIEY.4/M .. I 5�jMK <br /> +�} <br /> EN u.is f� *4 <br /> ♦ <br />