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<br /> hPPLICATION FOR PPSRkIT
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<br /> SAN JOAQUIN COUNTY PUBLIC HEALTIi SERVICES
<br /> ENVIRONMENTAL HEALTH TiIVISION
<br /> _160I"E.- HAZSLTON_AVE.--,__PHONE 20
<br /> (209)968-34
<br /> I P U Box 2009, STOCKI CA 95201 -- -- _ _
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<br /> r R R TE 10MM
<br /> (Complete iti TrinTf, ate)
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<br /> -AppllcntloR 1a hereQ, tonAe to Se.n Joaquin Covnty for a pc.ru t to conr'.'::et nrdlor install the work herein described. This
<br /> 1 1 application is -xrle in cbmylfanee vtth Ser J„Sa,:1R ccuatr ordinance No. S49 and 1862 end the liaise and Be
<br /> dulwttone of Sen
<br /> Joanutn Cowtt•- ?urilc Rea3th 9ervJcea.
<br /> Cnv�C�G - j.ut t31r-c/Acrewte31
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<br /> Job Address _4x
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<br /> Phone .-
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<br /> License No. iZ ptwne
<br /> _ �?
<br /> PEST RUCTION t✓WL OF service well L7
<br /> Contr3clgr •,ryELL REPtACEti7FNT 1=i
<br /> Y=� -•^1"'"- - NEW WELL �I Y&nitarinf3 Well
<br /> { i i'' TYPE OF 14cLL1't1�TP. gVSTEM REPAIR LL
<br /> ATHEit ❑
<br /> PUMP INSTALLATION ^; DISAOSAL FLD. POOP,LINE '
<br /> SEWER LIVES PITSS/SUMS
<br /> DISTANC5 TO NE,-REST: SEPTIC pGRfCULTURE WELL _ �T OTf4ER WELL_ ��
<br /> n
<br /> h FOUNOATION�� --
<br /> TYPE OI'WELL PROBLEM AREA CONSTRUCTION SPECIFIC:TION5 Oia.OI Walt Lasing,
<br /> i INTENDED US.- -- Manteca Di+-of W'ex E,cavalian_ �
<br /> «Ppsn tiol[em �-: SPecilicatiors,
<br /> �4 `' { CI tndvsuial P Tracy Type of �-
<br /> �t rte'` '"C1 DomasliCl Private a Gravel Pack Type of Grout _.-��
<br /> _ f 1 Pella Oeplh L Grow Seal '"
<br /> !a OV,e•
<br /> Public 5u,faca Seal Instanrd by --��'-
<br /> APtraaglare.elep[h I I£ef:ernv.•
<br /> H.P.
<br /> Work Done
<br /> Repair tR/OIII Done i.".• TYoe Of Pu'w . ct,r,lirA Material h Day th _ ,Y
<br /> f Lie:Dia•nn[a, r
<br /> Well Destruelion C t Tiller NAterial i Ewptl
<br /> n ✓ - pet,lh ---�• %A
<br /> ti- available w,thm 700 feet.,
<br /> > a TYfTIG ti4Ugr--�tiEW iN`+T AL LAIEON I I ftEPAIfi-•Ai)G!l1L'N Pt;i RUCT10N•I I INa 4st`t'C system perm,tF+ld,I gIbIK sewer n'
<br /> �1
<br /> 3 k OF SL
<br /> Other
<br /> A lnatallel,on will serve: Fal,enc, J COrn,ne,c'0l f--/y
<br /> Nuinbr of eJedrooms �a�+ �Wstsr tsNs depth r
<br /> S.r NUrrlbar of living unit L:�� _��j ,, --
<br /> r* CMtacter of sail rn s depth or 3 leek. r Cer-acitYQ- No.COmPTA�^ente .
<br /> ;. . G Type!Mtq �(
<br /> SEPTIC TANK _ Me:hoJ a}Dispoal
<br /> �xrr T
<br /> U PKG. TREATMENT PLT.❑ Plopemy Line
<br /> �i M Fow,tlnt,on
<br /> �- - Disttlnca to nearrsl! Wall�L�' _
<br /> �]—._�.t�r�— — _ 'seal Ienglhl Nr+
<br /> .( No H Langlh oI Imea s �r PrtlPerSY Line ��'�
<br /> . LEACHING LILAC /� ��. Foundation- �--�' -,
<br /> I)isun[e w nearest: writ%. --'- _
<br /> :FILTER BED
<br /> Number...^—�..�-�- -
<br /> Srre - property line
<br /> •, t s f - SEEPAGE PITS t I (;~,Pth ��.- Foundation
<br /> - SJMPS F-1- Ostance to nearest: Well
<br /> �,:' DEPOSAL PONDS IJ Us
<br /> t hoieby family[tial f have P,ePe:ed!1»s appt,calian a Inst Ina waren ytrhat ro thanperformance O!t ha woJv Or IwR'Ch this INIM11 n Issued,1 el+all not
<br /> rules and ra6u:etions of the San Joaa +n Catu,ty stwo
<br /> Homa pwr-er m licensed agent's srgr,atwe cemilrea iiia foltOwlnd. 1 shall smpioY peraOns wbleft to wnrkRyn s eornpensa•
<br /> emPIOY any Perron in s 4 care taste n the"r s 10 x1niwmubrecolt na`+am nig co c n�a perm o iuued Of itornia.' [ontuctors hiring Oi wacOntraCt;nq lige
<br /> a ✓
<br /> �l r,r.. 1 families the tcslowinq
<br /> N' 4. 1='.'tion laws yf Lalifprnia." me drawing on laverw side e�
<br /> ' The aPPticar!:'vast tail lot all{aUuired ens>IectioM. i;ompl
<br /> Date:
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<br /> Signed �'-
<br /> +, FOR DEPARTMENT USE ONLY
<br /> Osu `� r Ara'
<br /> �c`GLz f
<br /> Maio 's O
<br /> ApPlitalinr,Accapled_bV —T. Date Final Inspection by
<br /> Pit t f Groat tnapa^.tion by
<br /> Old rx,
<br /> tFv r- a Additional Cammants: uiP Coua:Y Public Bealtb
<br /> Applicant Return all COP1aa to: San Jces
<br /> _ Services, DCo=ntarntsl Health Permit/$erylces CA 95201
<br /> 1601 F. 1'ALel'.on Ave., P 0 box 2()04• $LeCktOP•
<br /> Y CK.7 RECEIVED By DATE PERM17 LA0.•
<br /> ,� _ 1 ^� AMiOUNT kEMITTED Cp5,1
<br /> r - FF1 AM.JUNT DUE ���
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