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APPLiCATij)tr FOR I'EPX17'
<br /> SAN JOAQUIN CI:iNTY PUBLIC UEALTH SFRVICR5
<br /> LNVIh0NMFNT.(L IIE:II.TII DIVISION
<br /> 1601 E. HAZELTC•N AVE. , PUONE (209)468-3420
<br /> P O :IOC 2009. S' OCPTJN, CA 952U 1
<br /> P BIT RXPIR l-YJ:. 4 tl(QII DATE ISSUED
<br /> (Comp)eto is _; I i<!atc) "
<br /> Axlieatioo is hereby mde.to San Joaquin County for a Prra:t 'o cxrstr,: o:CVcr instw11 '.he work he:e:n dca^rlbe'. :his
<br /> application is Lode 10 cdnplisnce vitt.San Joaqu:c Covr.•.y r -S:nance co. ;:r and 1962 ant! the Rules and Reau.ie..loee o: Se:
<br /> Joaquin County Public Health Services. e (� t r ?
<br /> Jo0Adlteas O jf M Uf_'' CL-
<br /> .(�•'r C••, -�_i( L�_✓Y Lot Staeilcreagcjq� x 24
<br /> �t 11
<br /> 1'"i ep_n G tJ r e-- Peens d
<br /> Conllacta L :C-5f :i: -°wC'e
<br /> TYPE OF WELLIPU•AP fire.WELL .^, AIELL REPLACE'.!il.T DESTRUCTION o t or Service yell Cl
<br /> PUMP INSTAL.ATION SYSTEM REPAIR IsonitorinZ well
<br /> r.
<br /> DISTANCE TO NEAREST: SEPTIC TANr _ SEwER,I%ES ._...--__..__ DiSPOS.L F.0 PROP. LINE
<br /> FOUNDATION _ AGRICULTURE'.•zLl OTHER_rf:f.-_—_— PITSISUMPS
<br /> INTENDED USE TYPE OF WELL PROBLFIA AREA [0!iSTRUCTI0%SPECIFICATICNS I `�
<br /> it 41dua'trlel Li Open Bottom ;Manteca` 0.8 o1.Ven
<br /> Os of Well Cas,nq _._—f 'V7 I
<br /> (I DomeallefP11vale :.l Gavel Pack I'l,acv T,p•of Cev(q
<br /> I',PIIWIt i t Gth+er
<br /> i i Mtta :nom rt Gout S•a rvs of Grout
<br /> Apptos Depth i I Eastern Suria.•S•..,tnata•Ied I.
<br /> 1 I In lUatlon ._ "- —
<br /> Repslr Work Done L) Type of Pump -.- H P ._--_--- _—. Ste. ..,. :n.-- -
<br /> WON Destruetroh Ll WN Owneter Seall:a mate.-,&I 1 ^.r.th
<br /> Oroth- Filler Material L :•!pt'+
<br /> IYPC OF SEPTIC WORM. NEW INSTALLATION I I F LPAIR I AO D1 T SON W7 R1tCirf•' r s-c-r r.at9 Pal- d p„DI,c s•tvwr n
<br /> a.3: e•
<br /> ow , 17W test
<br /> Instatat.M Wilt ser-47 Resodence_ 1.Om",C41--. Otne• ._- i
<br /> Number 0 hvrng uWa.___L NI.-be,of bed,00r•Is
<br /> Ctwacar a cot•to s iaj,h of 7 Ieec- S a7�Yt D*__�_��' -.-.--.----..__... _ :e•ror to a4 depth_ --
<br /> SEPTIC TANK (.1 Tvpe/Mfg Cspacry_„_ __...-_ Na. G n+partrrvnta (T)
<br /> PKG.TREATMENT F:T.I.1
<br /> Distance to nearest. Wra L^undat pit------ rNjpeni Lwe
<br /> LEACHING LINE Pty Vo A Length of Iules _L5�,_._. Lr x k_ _ '-,a- 4
<br /> filTERyBED , meqvaoce to nufest. WON F as-)r. . i P.•,penv Lrne r a
<br /> -t4 jer
<br /> SEEPAGE PITS 11 Doan ---'-
<br /> SUMPS Lt DMtanu tet n"I"I. wen_---. Fo..Mat,un — ---.--- P,openv Lir
<br /> DISPOSAL PONDS Cl v
<br /> I hereby centfy that I have pr•Gared Itis appl,c Moon and tnat the.sats—1.W 0306•.,ac I:•a•In:e, th San Joauuut col,nty oryaanees.state taws.and 1
<br /> r
<br /> rules and reguisloone of the Sa,I Joaquin County
<br /> Horne owner or aeensed agent's atgnature con-1,e1t•t%o!O"++a.s•rtg I cenrfy(hat r„the pertor•nance or O's wen•for wtuc;%th-s permt a Mwed.I sham not
<br /> employ any person in such manner as to Decom•1,11300 t.,•gorhman-s :aces cf CaLf un•a'•Comtactor's hon q o,auZI-connactw+g u9natwe
<br /> certifies the following:'I candy'that In Inc P001W
<br /> man et the^or♦to,wnKh tea p•,n'.t,a•,wed "U en.0joy peraors suhract to wotkrttan s CORIV•,enaa-
<br /> tion laws of CaVornia.”
<br /> The applreanl m t call lot as requeed Insp•Cltors.Compt.te aiae,-o on ra-ase s,.M� � n
<br /> Signed Date: �� T
<br /> ~ Y
<br /> -00 DEPAFJIAAENT�J6E ONLY
<br /> Appbcat,on AUeFted by (.!_ �t',C/ -- Data. �� '/a' ./Area
<br /> Pit or Grout IMpeCto;q by Date F,ral insceatcn It �• r1_11z
<br /> Addttronat COMnOnts: /
<br /> Applicant - Return all copies .Sall Joaquin County I'-talc He"11,
<br /> :rvic•s, Ftvlronseeta: Health Pentit(Servicee
<br /> 1001 E. Haselt.on Ave.. P 0 Box :009, ,Stockton. CA 9520:
<br /> FEE AMOUNT DUE AMOUNT REWTT10 CASK RECENIV BY E - PE NO
<br /> INFO
<br /> .EM q7a IaEV t•+1i
<br /> ale 4.31
<br />
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