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<br /> SANJOAQUIN COUNTYPUBLIC HSP-L'1'� 3$RVI[°.85 i ri r „rM1
<br /> EMVi[R fflU iTAL MUM DI'VISIOF
<br /> q45`N:SAN JOAQUIN,:,PHONS (209)488 54 0
<br /> i 45201'' S k _.any, ,�ur�!'+✓e iz j r
<br /> P O BO% 2009. $TOCgTOl�; CA ane n 4{ "1 tT ` �"
<br /> (Complete in .TripliCM160 X
<br /> K
<br /> A"We•to Baa Joa4uln County ror'a'yerrait Lo construct awbr SaaSa]l a of ocelli SRa5t111stiada`of Sao +�
<br /> Jlltplicatiott:ie Mrs by
<br /> aypllcatioo !s aade in cc�liance with Ban Joa4ula County prdinaacr Ifo 549 + -1► �t M f tE : z
<br /> Jon4u1n County Publit Health Berricer
<br /> GtY Lot Ise Ac
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<br /> nb Atlo�e11a �.—J�� -� , �•1 �� x * �'! ' � F ,«,C 4 f�
<br /> + iagVtL $ 1 ' ° # r
<br /> Address i e I r rF;"r7a�S Y
<br /> ell,Mr s Name ' ji
<br /> arks
<br /> N.'❑
<br /> put Ott 3I 1 $ c
<br />' C n!racory WELL D • x WELEPLAGEMEN
<br /> 7 t�, a � 7RrUCT
<br /> NEW
<br /> TYPEOFWELLPUMP OTH0ER
<br /> 'OTHER,
<br /> PUMP INSTALATION ❑ EPAIR 0
<br /> d' NOrtt.l"ts�e�2t.
<br /> 1it113>*I ,ry x�`:t
<br /> 'fimv
<br /> ..
<br /> 4 _
<br /> SEWER LINES
<br /> T,
<br /> ?' DISPOSAL FLt?�_w-PRCY LINEN ,
<br /> DISTANCE TO+NEAR EST: SEPTIC TANK—'ASEWE ULTURE WELL' OTHER WELL `S MT5/5Uf�APS
<br /> FOUNDATION' .
<br /> TYPE Of WELL°• PROBLEM AREA z CONSTRUGTIDN SPECIFICATIONS>s,
<br /> INTENDED USE Oce of Wats E><cavatron =-•--
<br /> Ow d WaNi
<br /> n eottrxn CJ Manteca a
<br /> (1 IndustriNr, ❑Opr 0 Tracy " r Type of CA ng " 5
<br /> I C.l DorneatiCl Private C!Gravel Psck TYpa of of �
<br /> Cl Doles t OeFth of Grwt'Seal .........
<br /> I Public _ ;y, S` I I Other "
<br /> Approa Dipeh t I Eastern a n* ;,Surlaeet5ssl Inslsllad
<br /> I I Irtcgation M.P.
<br /> ' Stale Wolk Dons xc a sa3 x
<br /> Rapatr Work Done ❑' TYrx of Pump-77
<br /> 9ealias 1Mterial i-AePtI► y; a t ','�+x
<br /> Wap pattruetron t ❑. -Walt DcamaterL --+--- r :niliC�M6taYial`E-DrDth
<br /> Depth
<br /> lNa tr+E k At10E0 MiMrt 7/ t
<br /> TRUCTION f I raPlk rtYstarh'porrrtrl
<br /> TYPE DF SEPTIC WORK MEW INSTILLATION I I REPAI,RfAUDITION S _ ; avaaabu ti1ilMn- lgaf I ,�y ti� {' " M1
<br /> Rsadance GOrnit llfG111' E �r sy i2 5 t tx <� n6
<br /> .� Inataaation WR issue: ,
<br /> } Nu6tbef Ot bwfcc`na = "nay W tibbrtleplh� �i Gr
<br /> NR
<br /> Number of 11 nnp amts _i�- . t t
<br /> Ghrrseter of adl
<br /> to a depth of,3 leer — p
<br /> SEPTIC TAN!% d Type/Mlp Capac+tY RNG CWttpaltfhMtM J s'` st "+ "�t rc is
<br /> r. ' . �ProPY
<br /> PK6 TREATMENT PLT ❑ k
<br /> Datanc.toFiiarost { Well �Fourtdetwn :f p`c a' Rk� t3
<br /> 't r Tolef knythl�lsi
<br /> 4EACHING LINE Cl -n,3., Length,of liner ? ',_,h ti t'r x "'ak h+ Kier rS'�i,'� z
<br /> C7 Distanoa to rsaraat Well Foundatgn`7- {Praparry Lrylns ,t, j�ti F w Y
<br /> FILTER SED
<br /> SEEPAGE PITSJ.:-., - i 1 DCpth - "size
<br /> LI K Distance to niaraat WWI Foundatcon ProDretY l n
<br /> SLimp S..: ', " `a ' '
<br /> DISPOSAL PGNDS ❑ antil lawn,andr c
<br /> I Mrrby;tartcfy that I have prsperad thio appkutlon and that the work will be dons in accordance vnth 5a JoWuin J* tY�
<br /> salsa and r"kAtions of tlfr San Joaquin-Coiraty ' Mt'NE
<br /> µgnp,owrtrr Or titlrnaad agent's tipnatura rani".cM'ttw Iohowing.',1 eertFfY that in thr.psrlormanee o!the wrxk for wA+idt thi
<br /> empty any timson in aueh rmnnrr Asia beic me aubiact to workman s compertaatlor it 1; . Gih"I she ,Contraetot"a VA to wprltnlMr a 00t7tpa Mata ,*�, y_
<br /> u,rtif;as The
<br /> followin0:'9 csnity that rn tits psffomta-a of the work for which 1111110 ermit 1�iaruad l shell amplOY pHttIOM wb�ct q
<br /> ..:H ,: �, r= '1 1 t Jai s •et �,1s �Y3`�'�' r� 'xiJ4k kir "
<br /> tion lows of CSWOMLa." y ^"
<br /> Gomplatr dreww+p on rsvr
<br /> Tiro st U r aN segues Irt; + ♦ 1 , rf r v rp Ccri +, c
<br /> 5r1N J '• - .. t aN f,.'-ti a Pi e'ki'i°&xv �+^r A
<br /> { OA DEPPRTMENT USE ONLY Et iy: 7`r r !w S // "n+,'a,�'�x �T
<br /> Applwatbn,ACcrptadby � ✓ <} ,7, �! ' z'..r� M1 k.:.t, t {
<br /> < Final lnapaetion by
<br /> pats
<br /> Pit,x,Grout inspection by
<br /> y,ynianat.Commrnta:.� .. - --�' v .ems a, M1r �as°" : +F'.��.I'-•' � '°• r � K
<br /> Agllcant - Return ail eoP lea:oto s..SIL
<br /> aa liOPmentel�HsaltbuPermlt/9arwlceevices
<br /> .r : 5'11 ti
<br /> ;445:N San JoaRulnr..,P O Box,2009, 8tkrt CA B52O1
<br /> �. NECEIVEO 1Y DATE f x rERM1T ND? k ` ta � Si
<br /> FEE AMOUNT OUE AMOUNT MLMITTEO CA H
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