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y <br /> K7 <br /> :3PLICATION F,-R pgRMIT <br /> LAN .;CAQUIN C'UNTY PUBLIC r?�•.��, LT'= M�RYICES. <br /> YVISRON1 ZNTA.I. �i+;`.I LI7ISIOH <br /> � O BOX, 2004, :.TOCKTON, ::.� 95201 <br /> (209) a68-3447 r <br /> M� <br /> R Fi00 <br /> r Tc �•.�� l <br /> t gra ='4 ^'� R :1 <br /> complete 1- <br /> ^ <br /> CCretruc: arcler nst 'EM ,ons e:' San <br /> +tyPllcat:ea :s M1ereoy asae to Spa .;uqu:a Cavney Car n Ser^.': =- ,.T,�r�a,tr �� , <br /> ►F^JLSCRt1CC :a toa.Oa 1n :=LW.Ce vlttt San :uquin t:vjn •f Qr�::nnce HD. i-Y 'EMATI �V J <br /> Sills ti��:y P.Siie -t%ltL Serv%cea. , <br /> �I , �f� - �«, L ~c1n Lc: 51tevAeretsge <br /> .00 Atlatata li-�G:oT � V P f.ia Y /�/[�1iL t.',! _:V_�.__��^ <br /> rnl�. ` ;�,'�S•Lt+L c . „]� !IJtN �hari0 .4 <br /> f ver s <br /> Name vL. r... o »atlress ^r, <br /> .:+ GJ 1� 'r�N✓ / eI -lnSe Na. 7i ?^7n! C <br /> JELL REPLACEMENT C 3ESTRUCTION <br /> EDF G Lost oC Sarriee well ` <br /> r .' ELLIPUMW : <br /> P- NEW <br /> ELL = OTHER 9 'SQnitoring well <br /> 1 ?� � SUMP INSTALLATION = SYSTEM REPAIR C. f <br /> I5POSAL FLO.� PROP. UNE <br /> DISTANCE TO NEAREST: SEPTIC TANK S.WEA itNES PITSISUMPS ' <br /> s COUNOATiON AGRICULTURS WELL vTtIER WELL <br /> i .'NTENOEO USE -vpe OF WELL PROBLEM AREA :INSTRUCTION SPECIFICATIONS <br /> _ Cia.o1 Well Casing <br /> ";ntlustna, <br /> ',can 13attom = Manteoa C.a,at ,veil E:cavauon�� <br /> &lie 4 a rvC� S-euucations t . <br /> }-a0on,saucr Pnva+e 'sZ 1313.61 'rtes :Tracy ";ps of Cuing ' Type of Grout_ `-`�"r <br /> „til,t OmarDelta Deotn at Grout Seal <br /> Irngeuon Jj,1,v:+r- Approx.Oaatn Eastern Svrlaa Seal tnsutl+O°Stats Worr Done_ <br /> Rvnr Worr Done C_ Type of Pump H P. <br /> d Destruction. CI Wad Sealing Oismeter 1111 <br /> 5 Death _ --- Tiller Ilsterial i Depth_ _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 4 FiEPAfRIA001TIQN DESTRUCTION_ ;Vamp`+SWI Irk 200 Ga�tif°'t puauc saw+,is C <br /> .,,.,Mallon wtd cam.,. Rssiciri— Commercial_ Other_ c <br /> C <br /> Numlov of livrfip units:— Nuntoer of oe°moms Water <br /> IChara <br /> aer at sad to a pFier: No.of 3 FieC <br /> No.Gnmpartmants c <br /> f PTIC TANK G TyyeJMtq Caoattty� ; <br /> Mstriaa of Gisptla+l 12 <br /> �rnG.TREATMENT PLT-C: <br /> �tcDor[y Line 1� <br /> Gitanes to neatest! '.Vett "rountl+tuan � <br /> i <br /> i-JACHING LINE '+o.A Lengtn at lines -:,.at:engtnisrle <br /> FILTER BSO ••� <br /> Mstancs to nearasf: veil =tuneanon �raoertr erns <br /> "EPAGE PITS t Omtn Sirs 4umoer 1 <br /> E <br /> SUMPS _: Distance to neatest: well Faunos ion Property Line�-- <br /> DISPOSAL PONOS <br /> �uepr candy ilial t nave onoarea tars applicauan ana ilial the warn will oa sone n accortlance wrtn San aoaautn county arornsncaa•stets taws. ana <br /> 4:-piss and requtauans of trio Son Joeaurn Coua:y <br /> Nvms owner ar ucsnua spanYs upnawn cenrhss ilio toeowrng:"t :slid.fn+f in the oenor^+ance at:fie wort for waren this ostmu s r11i I snail not <br /> +motov any r of llcaft rt such 8"I'amiann to txeom+s Ina f to wanman s cornoensauon:awl or Cs:,tornu.'C.-nlrgelof s filling Cr suo•contraeunq ugnawre <br /> t 11Indiu tris toncwmp:"t csrnty trial in tris aenotmance of file wars for wmcn:at oermn,s.cawed.i$nnu smatov parsons auoiect to wanman a Comocnaa• <br /> I_ n laws of C+lila+nte." <br /> r, 1 <br /> The epotuan list;all for lit nawree ins c a Gallia eta crowing on averse s,oe. <br /> Osie; r <br /> � ;rgnatl Tidr <br /> ` r f FOR dEPARTMENT USE ONLY f� <br /> Arae <br /> Appl7Csttan AMONG by Date <br /> .moi a[ <br /> .. <br /> I ,It or Grout Inapeanon by Cate .�_. Final tnsoecsien ay / <br /> f � <br /> ` )snot Conlm9nte: <br /> f ,Pylielnt - .11turta all Ccples to-, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRCNWFNTAL HEALTH DIVI3ICN PERMIT/SERVICES <br /> +*f1 445 H SAN JOAQUIN. P O BOX 2009, 3TUCK-C.Y, CA 95201 <br /> :ii'CEIVE7 BY t ,assail No. t <br /> ftt I Ak4OUNT DUE AMOUNT M1EA1rrrID j r tK _ TATE , <br /> .�i jT 141RIV r1,11 <br /> i:a•al <br /> j <br />