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41 <br />Sates' JOLQUiN C'JUN= PCF.LIC Ea6.7.7E S=V10ES <br />ENMAIRON'XMrl-AL HEALTE D.'PISION <br />445 h SAN JOAQrIN , PHOIr'E (209)468-3420 <br />P 0 BO]C 2009, SZ =TOO , CA 95201 <br />r 3t' T T <br />(Complete ,n Triplicate) <br />1M34tation is breby made to 6" Jo"ui= County for a perdu tP contract &War lostall the work hereie deseribat. Tbis <br />anlication is ti"t in eon:lance vitt San Joaquin County OrCinancc Iso 54 and 1862 mad the Rules aaC Reavlatiooa of baa <br />JOogttip County PUblle health bert'ieaa. <br />I A 7 %A, if — C—' ,, —1 17 A/'t/ <br />Job ACIOtoW . I v✓ <br />r f r n � 611y <br />CTT <br />D F 74AC AZO `T"RfK 3L �D, TieA G p�„e ZO 36 ��Z0 <br />Owner a Name <br />Aaarest <br />WbI 14AL�A Ab b t% '*140 ft�swzLQl' 3t�2�{ G. <br />l%*Sr Sh�'/R11M C� Phone <br />ConlraclorCIAOU,�WATFki4^I+.,rOC <br />6V Address N Llcrnqb _ <br />TYPE OF WELL/PUMP <br />NEW WELL M WELL REPLACEMENT E 1 DESTRUCTION 0 Out of Semee well to <br />PUMP INSTALLATION D SYSTEM REPAIR D OTHER D 1lattit4rint ►tett <br />DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PRDP LINE. <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ., <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />Cl Inoustrral <br />D Open Bonom D Manteca Dia of Well Excavation h fdcO Dia of WOE Ca" 1 KCH <br />ri Otxr.est,clPrlrate <br />!ZGn1re1 Pack D Tracy Typo of Casino PVC Spsctflcauons S tof P P '40 <br />M Public <br />n Otner n Delta Depth of Grout Seal Type of GroutNFf'r C=!~.✓ <br />I 1 Irrlpatltxt <br />Repair work pont 17 <br />_ Approu Depth I I Eastern S 11ace Saul Installed 1)y So rG S �X �toi;.�r/0..1 �eFRV/Cfx <br />Types Pump A H P INVA State work Done IBJIA <br />Wel Destruction O <br />of _ <br />wet Dlsmeter 2- l w!G baalioS It.t;erial i Depth to u -� -/' ...ray✓,» -'! /'-3 • <br />Depth ^' Z S i= T idler haterie.l ♦ Deptk `�AA/� 3 �� - 2 0 - <br />TYPE <br />TYPE OF SEPTIC WORK <br />NEW INSTALLATION I I REPAIR/ADDITIDN 1 1 DESTRUCTION I I INP septic System perrm9led if public server a <br />avauahle wrthln 200 1ee1.1 <br />installation w1Tl serve <br />Resmsence — Commorcul ^ Other <br />Nutrtper Of lewtp units <br />Number of bedrooms <br />' L`imwaaw of sell to a depth of 3 test Water tabic depth <br />SEPTIC TANK <br />D Type/MIo Capacrty No Contpartmertts <br />PKG TREATMENT PLT <br />13 Method of Disposal <br />Nuance to nearest Well Foundation Property Lr.e <br />LEACHING LINE <br />Cl No i Length of bees Total lenpth/atte <br />FILTER BED <br />D Distance to nasraet Walt Founaatlon Property L1rw <br />SEEPAGE PITS <br />i I Doth San Number <br />SUMPS <br />Ll Dcawww to rwarmt well Foundation Property Lures <br />DISPOSAL PONDS <br />Q <br />I hereby prtity that I have prepared the applluaon end that It* work .way be done s1 Accor"nce w.th San Joagvin county ordmances stets laws, and <br />+ulna and repulatmew of the Son joegwm Camly <br />Matta Owryr Or 60WNW apart a agniaturs aww1we the tokow+na "i Oertrty that in the parta=nanee of the work la whteh the permrl s waved. 1 stcsll not <br />aetOlvy OW Iceman n aLeM wonftw as w b corrw suhteCt to wanntan s comweneatlon lava of Caldorrra " Contracices h"V or outyGonnactrV alp wwm <br />IarW- ecu tobwminp "I certtty that 1n the peRorzrwice of the woA for w wCh this pamrt a.stied I shall arrtptoV persorts subject to workman a C*w4 dna► <br />bon Wag of CaTrlonftla - <br />Tt» appleant rrwst CAN for sal reouesd rnay.e:dna Gomp+esa arewrno oen <br />n rraa+aa <br />Sgrrd 7C_.—�3 %i • �� TitleAS'5 ►Cl t-rF CFr 64irT Date 1,7- z_3 - f d - <br />t. r FOR DEPARTMENT USE ONLY <br />ADpWauon Accepted fyY b i �-f^4 Dat. -2-7 tI f� At" [ .�.�• <br />Pit Or Grout In114601or+ by <br />Aodniomt Comm-mms <br />1 r f , I_• <br />base Final Inspeetron by <br />F <br />Applieaet - Returo ►11 Coale`, to Sas JoaQuia County Publle bealtb ServICes JAN EPrlropaeetal IieiLItt Permit/bervlces JAN 2 6 1995 <br />445 h Sac JDaQuis. P G hoz 9006. Stab, CA 85901 <br />• t11 tV^ IRN lima <br />F►1 WIN <br />INFOw41DUNT <br />DUE REMITTED R C-KSM � RECErvED by D <br />_ - - - <br />o <br />