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SAN JOAQUIN COUNTY PUBLIC HEALT11 'FIERV�198_ <br /> HfqVJ11,)?MXNTAL WEALTH !DI VISION <br /> 445 ' SAV JOAQUIN. PHONE, (209)4,13-3420 <br /> � <br /> 11 0 IJOX 2009, :;TCN <br /> XTON, CA 95201 <br /> PELWIJUAL <br /> Application Ss hereby =sI[ to 5" jr.;;uIrl Q'..!!'y r"r A I'r.!t to coca tract endfor InstAll the work herein described. Thiii <br /> application to mde in conplIance vltY� Un C.--y Ordinanc,7 No. 5L9 and 1]61 and the ftlem And RoaWAttone of San <br /> Joaquin County Public HeiI Service'. <br /> Job AddressC', <br /> O-na,'o Name Phone <br /> contlacl(se Alld—LLI;C_bdld,!s% L,,e�se fdo Phone <br /> TvPf OF WELL/1-UMP 11 NEW WELt rWEI[ HiPLACfPAINT DESTRUCTION Cl Out of Service Veli 0 <br /> PUMP INSTAII-A7101i '_1 SYSTEM REPAIR OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST!: SEPTIC TANK S(WE4 LINES DISPOSAL FLO___ PROP. LINE <br /> II FOUNDATION ArRIEWTURF VILLL ____ OTHER WELL PITSISUMPS <br /> INTENDED VSE TYPE OF WELL PROM FAA ARTA CONSTRUCTION SPECIFICATIONS <br /> indvoir'sl C;Open Bottom Z5 Manteca Drs of Well E,cayston 04 of Weil Casing <br /> y1oomestic/Pti-ato i 01 Gravel Pact, r. Tracy Type of Imsmo Specifications <br /> I'l Publki 0 Other (-I Delta ()aPth bt clfrul <br /> 'col Type of Grout— <br /> I I liliuslion —Approx. Oozrtl asitrin S SP&I 1h.ra;Ivd by ;;t <br /> 5Tw*u state WorS none <br /> rior�ir Work Done X_ H P. <br /> Well Destruction 0 !!Wait Di.., <br /> Seali.n� iia tenial A sept' <br /> Dep,h Piller ga.eriLl. A Depth <br /> TYPE Of SEPTiC WORK:E NEW INSTAt.LATiON I I RV%AIR,ADOITIC;N I I 1)IS'WUCTION I I lNo septic system pormoled or linibitc hewer a <br /> available wonin 200 litait.) <br /> Installation will carve: Residence— Commercial___ Oiler <br /> Number or living umis! Nom6te el bedrooms <br /> Cfwbcsor of No to&davin of 3 toot: _--Water I"death <br /> SEPTIC TANK C1 Type/MI9 'I <br /> c1pac "-- No. CG " <br /> mp4rtn:s <br /> PKG. TREATMENT PLT.0 Method at Disposal <br /> Distance to nearest: Welt Foundation Piopefly Line <br /> LEACHING LINE Ll No,A Length of lines Tota!langth1s:,lit <br /> FILTER BED n Diataricis to nomelifiL Wall foundawn Property Line <br /> SEEPAGE PITS I I Dapch Number <br /> SUMPS LI Distance to nearest: We# Foundtlion Peoinarty,Line <br /> DISPOSAL PONDS 0 <br /> I hereby cart-ty That I Int-olpropared ih4 3ppticarioo and ihat:ht,work will ba Jane n Bccoidan ce with Sart Joaquin County ordinances,mota law%,an <br /> ruses and recuts I in"of the San Joaquin County <br /> Home owner cir liranbod iiiiI ipgrioture oenol4s the lcllowmffr"I certify that the ocrfir)imanco at the work for wilhich 1hos permit is issued,I shall hat <br /> emp+oy any porman in such ffwnrAr as to bacono subjeci to voo(krnon't Compensation Uwa of Cal,lofh4"Convaclo"s lhitmg or sub-conlFacling vqnsluns <br /> cistlifies Ilia follone-ing!"I certity that in the performance 01 the work for which thix Torm,l is i"nud.I shall employ persons ilijbIOCT to workman's cionsti. <br /> tion It"of Calito(oto." 4- <br /> The zPPIic4in!,Pw%1—c),3 fo(j&A reI i?pdetions. Compials d,@-,,%Q 'a -11. <br /> Dais: <br /> SSignaff tTitle: <br /> FOR DEPARTMENT VSE ONLY <br /> Api-p4calitin Accoolm-by Data Aram <br /> Pit of Groul.Inspection by Data Final Inspection by Data <br /> Additoonof Coenrneeiiv <br /> Applicant Return All 0.plirS tC: Sir Jomq,,In f'..nty ]5;bltc health 5er.r,_4­ <br /> Ifealth Iler-itPlierviceo <br /> 445 N San Joaquin, P 0 Box 2009, Stit., CA 4.5,101 <br /> FEE <br /> IF DUE OUNT AEPA11"ItO RECEIVED BY OATS PERMIT NO <br /> EN'1_ [.11, 5' — AT AM '; <br /> I, <br /> A <br />