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APPLICATION. <br /> SAN JOAQUIN COUNf'YI PUEL-IC RTALTA SERVICES ' <br /> ERVI RON1dOTAL RRAT T1iI DIVISION <br /> 5 SAN JoAQUIlt i�, P#bN$ (209)468-3420 <br /> P 0 BOX 20094,' 8TOCITONt CA '95901, <br /> OM DAT <br /> (Complete its Triplicate) <br /> AppliN iar3 ii fleffby stdd- fo Sato} Jos o!A CdtWty for a per>flil 10 icoiislruct and/or install the work herein deecrLbed. This <br /> applir!itiotl !i 'tt>sdL iiia 6EJdtpifaitdb 1riEh &ud Joaqultl County OrdiBnnea fid: 3Lg artd i86H and the Aulle e>aa Regulations of Sari <br /> Josquilf Couhty Atblid Health Seirnri@eti: ;:•;c ,..•,r •. , 149 ' <br /> Job AddresaCit <br /> y� � %.oi siz S &.ChQd'° <br /> w e/Adt6&ge <br /> .Owner's NArtte jftt— }., ;� Address <br /> Pv �u }. <br /> Phone <br /> N43� <br /> Co6trac.o. ._ L 1:04 Address � i2LIcnsf Vo.(P1I ] <br /> TYPE OF WELL/PUMP;- -� N WELL: REPLACEMENT f] DESTRUCTION ❑ Out of Service Well <br /> tPUMP INSTALLATION ti ,�f. SYSTEM REPAIR ❑ � OTHER� 'ter ei4oli o Eng Well 4n <br /> p' DI$TAN3s� TO,NAES .iSf`' IC T/1�JI� SEWER LINES -i RJro� <br /> i7lSPOSAL ELf). 1t PABP. LINE / v, <br /> FOl1ND016I4 _, _ AGAICULTUAt WELL.< OtHtA WELL <br /> INtENDED_USE t —' PIT$/SUNTS" ,�t <br /> CNSthUetiON `1TYPEOFWEL PROBLEMAREA O SPECIFICATIONS <br /> k <br /> h <br /> f Industrial 'Cl dein BottomCJ MantecaManteca Die. of Well Excavation 7 t f. Die. of Well Caging +� <br /> i n Dut"1 606/Private 4 C1 Gravel Pack* a C) Tracy Type of taiing- l�L_, Specifications <br /> 81 ma <br /> ` I"1 Public - <br /> : 1:1 Other { Delta DeI]lh of Grout Seal SIA Tpa of Grout e- - -w <br /> I I Irripalioti, �I Y ,.Approx• Depth I I Easlern SUrfadi 5eul Initialled by !LF�'� 0,7 <br /> Repeir Wgrk Done f.] irypi:of Pump H.P. State Work Done S D1 L 901Pl/V G i <br /> Well Oestfut:tiah b Wall Diameter Sealing Material i Depth R"IL t I 1 <br /> Qepth _ _ Piller Mat,tri�i i'bepth , Az ZA <br /> TYPE OF SEPTIC WORK: ; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted If public sewer is <br /> S ( 1 = I available within 200 foM.I <br /> mmanitibll mli 1im4f_ fieaidiiii l4^ ca st sal^ Other <br /> -= i <br /> _.Number,of OVIA4 unite: A. Ntambei of bedrooms_ <br /> Charkettft of W 16 a deoth of 3 feet: <br /> Water table depth }�I <br /> SEPTIC TANK F" d Tym/Mf$ -r Ca acit <br /> P Y - No. Ctampartriienti <br /> PKG. fRf?/ITMEN'F PIT.Li Method of Dktposat - <br /> t I i Distance to rlearasti I Well iFouridation Property Lime <br /> I LEACHINO LINE'„_J. L7 N6. b,tength of Ilneb'= _ _-_ Total 16691th/size <br /> L <br /> FITER ffED 1 C1 Dlstance io neatest: Well <br /> i r i , � Foundation�i Property Lina I <br /> 1 SEEPA61 Mfg i t i I Depth } i Size, � <br /> _ i <br /> SUfylfyS l Numbei t 0 Distance t6 tteattlet: r Well Fouhd6tion Property Lina F <br /> DISPOSAL OQNDS i .❑ i s <br /> ( I hereby cattify that 1 have Orepired thlti a(aplicdition and that the work will be done in atcordanca with San Joaquin ebunty ordinances, state lbws, in; <br /> rulats and fegUIS116ni bf the Sin Joa4uln bouety f <br /> f Horne owner of liCeni$d 60int's itignetura cenifiss the following: "I 66rtify thai in the paRormanea of the work for whicth this permit li issued, I shell not <br /> employ any*son In riudh Mannar As to bscoriid iub]eCt to workmar+'s corhoansatldn lawn of California.”Contractor's hiring or sub-contracting signature <br /> certifisi this 19116N bing::•'_'l t:attify that in ihi frsrt it iAnb6 of the work for which this permit.it issued, I shall employ persons subject to workman's compensi- <br /> 7 o6n Iawe of Cil 61,0161,1# <br /> $he applicant e I for all f" irafl ins t e drawing ori rev Ida. ` <br /> i Sigftatl ' _-•..,+-. ..✓€ titli: t K i1. + bite: �r <br /> Ef�ARtIVIONT•Ubt ONLY <br /> ApPltca'tkan ACt bt6cf ey. - ` C1ata E ' <br /> Pit or Grout Inep�dtwri by ' Date - r �} <br /> - -; �.._ Final Irisribotfori by • aata <br /> Additional Cert"hts:; <br /> Applictlnt s ttetitrri all cooled to'F Sati Joaquid Ciiuhty Public.Health Services /�t�+i �'"~ r <br /> € Sn7 roninetital IteAltli PePlfi1t/8ert18ee <br /> 445 tt 8an Joagtlitii P O Boit 2009, Stkn; OA 95201 <br /> AMOUNT btlk° AM6Ukt aiMl1-1 t b r 1 RECEIVED BY DAfE PERMIT N0. <br /> INlEO CASH'._ t <br /> EH ti- illlv.ti�St { <br />