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I <br /> rw � <br /> APPLICATION FOR PERMIT <br /> L SAN JOAQUIN COUNTY PUBLIC UAL`FH SERVICES <br /> BNVIRONVENTAS. HEALTH DIVISION <br /> P 0 BOX 2009, STOCSTQN, CA 95201 <br /> (209) 469-3447 <br /> ISSUED <br /> if <br /> (Complete in triplicate) <br /> ' n or insta]1 the work herein described. This <br /> to construct a dl <br /> - t t :r a tmlt of. .. <br /> [sun pe do <br /> ns <br /> San Joaquin Y sad Re <br /> k - Applicatloa Ss hereby made 9 fltila . <br /> application fee is coegrliance ++1Lh San Jua4uin County Ordinarsee lla. 5E9 and 1862 and the Rules <br /> tix .Joaquin County Public Health Services. . <br /> Lot Siee/Adreage= <br /> City + <br /> Job AddrnaI >;�1tiL�.'�� <br /> Phone 67-n-r M1 <br /> Address <br /> hOwner's Name��ti-�1---=- <br /> License NO. .11 One <br /> - - Conlracllx Atldress <br /> WELL REPLACEMENT fl DESTRUCTION ❑Out.of Servie! kfrll. sJ <br /> ' TYPE OF WELLIPUMP: - <br /> NEW WELL`• OTHER T7 .Ibnttorirts�tirll <br /> '— PUMP INSTALLATION C. SYSTEM REPAIR Cl <br /> r <br /> r c -f' SEWER LINES DISPOSAL FLO L� PROP KINE <br /> + <br /> DISTANCE TO NEAREST: SEPTIC TANK J�-- pIT$ISUMPS �513� <br /> FOUNDATION — AGRICULTURE WELL• OTHER WELL ' <br /> INTENEDIUSE TYPE OF WELL PP.O8LEMAREA. CONSTRUCTION SPECIFICATIONS L <br /> Dia.o(W- <br /> Open <br /> WsCsalrq �� <br /> z C3 Industrial. �T Open Bottom Manteca Oia.01 Well Escwst on Spaeifiutiom (a �] '. <br /> Type of Casing <br /> OortettielPriv&is C1 <br /> Gr"Pack ❑Tnry Type of Grout - <br /> I'1 Othw . ❑Delta Depth�f Grout Seal t <br /> Public .. <br /> I� ❑lingalian App os.OeP[h ❑Eastern Surface Said <br /> insulted by :F X.y <br /> RsPair Work Done 0 'T".of Pump <br /> H.P. Stats Work Dons <br /> ;1 Seal Material i Depth r t+ <br /> Well Deotruciron ❑ `Wall Diameter r, <br /> Ddpth Tiller Material fi Depth. '3 <br /> ' matted it public MrWA a-- <br /> > - TYPE OT•SEPTIC WORK: NEVI <br /> EW INSTALLATION L] REPAIRIAOOI NON❑ DESTRUCTION 01Nol$4513 system p'r fx <br /> ' - '. Wadable within I"I.1 <br /> E i <br /> r Inatallatioh will serve. Rxiden<e Cammerc;al Others i <br /> Ntimbet of Gvinq units:�; Number of bedrooms t <br /> :,. . .. Water table depth. <br /> 3 Cnarectst o} a&oil to depth of]feet: No.Comgattmentf <br /> SEPTIC TANK TypelMfp Capaclry � <br /> PKG.TREATMLl <br /> ENT PLT. Method of Qlspaul <br /> Distance to no res Well 'Foundation property Line <br /> f-+ LEACHtNG LINE O :No.6 Lenflth.of Finn <br /> Total lengthlar:a <br /> FILTER BrO R Disunc, 'e nearest:: Well anon Property Lino n <br /> r v <br /> Number - t <br /> -';"SEEPAGE PITS E 1 Depth e <br /> - - Property Line <br /> SUMPS, Lt O""'to naarnt: W'eN Foundat on <br /> 'r DISPOSAL PONOS ❑-` }r' <br /> t haiebi!crrtity that I have Prepared this APPhc:rion and that the work will be done <br /> in accordance With San JOsQuin County OrdrrYllNf aLtr lewvs_.and 4 <br /> rufss and iepulationa-of the San.Joaquin CourtY - I IIMIf n07 �» <br /> Home owre or tions of ae Sannt�s siflnature ceniliai the ton..•:"^ �.'9.cattily that in the performance of'ihs work lOr which rhes permit is iuued„ y.p <br /> i samploY:anY Wraon In such rnannof as to bscnme sublet to workman's comPensalion laws of California."Contract�Wa hrrinp w wcontractanp srgnatuu s <br /> caritNa the faNdWlh :"l Crfifty that in the performance of the work for which this pefmil is issued,f shat!evlplOY persons sublet 1D workman a CpfnpenY } <br /> -tion laws of Califor - <br /> F <br /> The e�pFcant, c .,•'an'r irrd its - ens.Comdete drawing on'rrvera.side: <br /> Tile: Oatr. <br /> Signed' <br /> r ` <br /> FOR DtEPARTMEHT USE ONLY ^ <br /> i �, h Date T1..'_�•y-� — Arra ' <br /> j S£ APPIat <br /> nlyAceepted by <br /> y ¢ _ <br /> Pit al3rout in; <br /> Ad- <br /> by ex- ale FinalInspection-bY Desi J <br /> ��// / <br /> Additional Com"nis ' <br /> `- t Applicant -.�RaLura all copies to. SAH JOAQUIN C01MT` .':.IC HBALTB BE VICES <br /> _n <br /> E7iV[RON8ENTAL HEA :IVISION PEIty1T/BfiRViCEB <br /> - 445 N Salt JOAQUIN. O UOX 4009, STUC`ItTtlft. CA 95401,, <br /> F <br /> REAAtOL+NT DUE AtkOVNT REMiTTEP K RECEIVED BY GATE. PERMIT'AiO. - <br /> :NFO CASH <br /> .C U GI..� <br /> fatty-7/I�fv,ri a&i <br /> 1 i` - <br />