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I <br /> JI. 1_10-1991 1 15:01 FROM AEGIS ENU I EOMENTAL. TO 12094640138 P.02 <br /> APPLICATION FOR PERMIT" <br /> SAN ,JOAQUIN COMM Punic HEALTH SERVICES <br /> 'SNVI IiQNIiBtl'T'AL MWALTS,DIVISION <br /> P-0 $tom X008, . i'QN, •CA 95$f)].. <br /> (309) 488-3447 <br /> (Complete in Triplicate) <br /> Application is htrtfI sada tq $ea Josgttin Cotmty for a yoratit to amstruct &Wear-ietstail tett work bereitl deveribed. This <br /> &VpUcatian is strode its emp Umwe vitb Saes Joaquin Couatr Ordlnaace Sq. 549 sad.1662 sad the Rules saga AeoL.ations of San <br /> Jimquin coustty Fublia Res4th Services. <br /> JobAdarrss J3 p•., st.ts�i�.�/ ", _ Cityc Lot s�setACr�W _ <br /> owner's NameAddressor <br /> �,�6r.+.rflsone e - <br /> Contractor <br /> . .1 •Address 33L {' , air• �, o�' Phone i <br /> TYRE OF WELL/PUU NEWINELL ❑ Wl:tt REPLACEMENT ❑ DESTRUCTION p OAt,o! Service =4_1 0 ` <br /> • ••� PUMP I NSTAI.LATTON ❑ SYSTEM REPAIR d OTHER OC3)vonitorin9 W*1W w I <br /> DISTANCE TO NEAREST: SEPTIC TANK&_JA' eVA SEWER LINES '�� DISPOSAL fi0,.���-_"P0OP. LIFE <br /> F*UNDATION AGRICULTURE WELLd OTHER WEL4Zi -afr-- PITS/SUMPS(!,*4-40" J <br /> INTENDED USE TYPE OF WELT PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M tndustrial © Open Boston► j Manteca 04. of Well fixcavatic �� Ola. of Welt G <br /> g Doeomic/Privas• )I Grdvel Pack Q Trarzy .TYPO of Caaft,..Azole SpaCif;cati0ns <br /> M Pow " I'I t?thef 0 Delta Deviih Of Grout Seal ^r r Twit of Gr '* <br /> ind <br /> C1 T:rigation _...Await. Depth ❑ Eastern Surf±ew Semi Instailert <br /> Reoair Work Oahe L? Type of Pump H.P. _ State.Work Dont <br /> Wer Dwstructilm Q Weil DIBrliater .... % Nateriat 4 Depth <br /> 00th Pillar Ii&UrIal i;bvptb > <br /> TYPE OF SEPTIC AY.: NEW'INSTALLATION.� REPAiRrADDiTiQN ESTRUCTION Cl iNo septic.systen't permitted if public sewer is <br /> sm JOAQvi�t '-'PbWL c HMTR S= C�,j <br /> insgaation vA swrwe: AnkIerm...r.,, Conwr►wmW— Other - "- ONMBNTAL HEALTH DIVISM <br /> NurMW of Av"Vfthr Number of bedroorr►aI �. <br /> CMraCtar of tloil tai depth of'3 fog: _ . , .r., - s7t <br /> SEPTIC-TANK. O Tyas/Mfg peony No, Cpmpert"Wrts _....,..� <br /> PKG. TREATMENT PLT. _ Method of Diwp4 W <br /> -€?Mance t4"as", WOII Prop"tine. ^ <br /> C <br /> LEACHING LINE Cl No. E Length of nn" Total t�npth/si7y <br /> FILTER BED 13 Dlitu+cs to rtawm.. Wen�,.,._ Foundation Property Line .. , <br /> SEEPAGE PITS I 1 Oapth Sitar Numbe <br /> SUMPS L1 Distance to r+aartst: ' 'Well_ Foundation- ProWW Lime <br /> DISPOSAL PONDS ❑ _ <br />' I hereby cOriify that I hew prOpired this appiicatiao and that The work will he done in accordance with San JoNuin county ordinam es, state Ism, and <br /> rules and rpvlatiorw of the Son Joaquin County <br /> "*"ownfr br licensed agent's signature otnifin the foltoyong: "I certify that in tho performance of the work for which this permit is issued. I OW not <br /> employ any parson in such nunner as to.becems subject to workman's compensation liven of Csl OrN&."Contre torrs hiring or suD•contmcTin9 sjagnOtuto <br /> r eartdiws tht fottowing:"I Ccsnify that in the peRom+ance of,ht work lot which this pOm>it is sewed,I shall arnptoy persona subject to vowirnan's compensa- <br /> tion Ism of Calife rnW." <br /> The of t nail foe els requhwd inapetions. Corttplste drawing annrra�wrrrr sitle: t �,t_ i1I+�Yer.►.slla►!�l G• <br /> S hen Title:3• "A' Qi"' - Date, <br /> ,Poll DEPARTMEW USE-ONLY <br /> Application Acctpl&Z 49 <br /> UJ 4 4--_5 �MZ_Tata � <br /> Pk or T rout Ittspeetian try i3at.� f Ftrtsi pn by Dsca <br /> I <br /> t Add'ItlarN Coenmanti: <br /> Appli4oAt Return all aepies ta: Slut JOAQUIN tCM= PUBLIC M&QT8 91MVIM <br /> ENVIRMIIEMTAL HIALTH DIVISION P3UI7/S)MVIC89 <br /> 446 it SAN JOAQUIN, P O l= 2009, STOIXTOtf, CA 96201 <br /> FEE AMOUNT ptJB ANOI=NT Ft(AtITT€Q CASH R <br /> 1tif0 €CINto BY DATE PIRMI7-NO. y. <br /> fW4 Ifttv,It a 61 <br />