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F <br /> APPLICATION FOR PEIwIT <br /> TII <br /> SAN .T4A NVTRON TAI. fi5A1,T DIVISIONAy10ES <br /> r ' p O BO% 24209 $ 447 83PAYMENT <br /> CA X5201 RECEIVED <br /> R 5 1991 <br /> (Complete in Triplicate? <br /> the v ..�i■ <br /> _ emit to construct and/or, <br /> inaan8 the Ru�bj�� <br /> Application is hereby <br /> ride• <br /> San Joaquin <br /> Count ENVIRONMENTAL Ordinance No. 5 9 ENVIRONS+hENTALHEn;•ftr:i•riaiOT! <br /> applicatlen is Mae In coria Lot HLse/Acrc&ec <br /> Joaquia County Public Health Services. ff Q City <br /> JoD Address C Phone <br /> p p, Address g3 _727. <br /> Ow��a Name <br /> Mo r3; VA l�(F19 <br /> _ �Nd`�' t5cense No.�� � Pnon <br /> 71n� iG well 0 <br /> Addl¢ss� Frc. CTION ❑ Out of S+rules cell <br /> Contractor ;llar 'LMA, WELL REPLACEMENT l" 1+oaltorin9 J <br /> NEW WELL OTHER 0 t Ta Cy WCC[5 <br /> TYPE OF WELLIPUMp'� SYSTEM REPAIR ❑ pgpp, LI E <br /> PUMP INSTALLATION !] DISPOSAL FLD._.�.�- PITSISUMPS <br /> SEWER LINES 1� OTKER WELLr� <br /> DISTANCE TO NEAREST: SEPTIC TANK �--- Ac, y --RE WELL <br /> FOUNDATION �� <br /> TYPE OF WELL PRGBLEM ARE0. CONSTRUCTION SPECIFICATIONS <br /> Dia.of Well Casing <br /> INTENDED USE ��� ❑Manteca cr� Dia.of Weli EKcava[io�-z-� Spttrlications-�-�� <br /> Ll Indus[ri ❑open Bottom TYPe of Casing a'7 cEw£v_i <br /> Gravel Pack C7 Tracy rVrN• F S TYPe of Grout NIS <br /> ndVsjni Pdva+a 0 Delta Depth of Grout Seat ��� �� 4 42,RP. <br /> El Other SuAa <br /> r cs Seur Installed LY Sr <br /> 13 Public �APW <br /> or. Depth 0 Eastern $tete Work Dona- <br /> "- ❑1tr�pan°n H.P. th <br /> Repair Work Done L7 TYpa of Pump �� Sesling Material k De P <br /> well Destruction 0 Filler Will Diameter - Material i Depth <br /> emitted if ublic sower is <br /> Depth ��� <br /> able within 200 18111.1TYKE OF SEPTIC WORK: NEW INSTALLATION!� REPAiR1AODITIOft Ll DESTRUCTION G fNo able <br /> sys <br /> ava [em pe P <br /> ce, Commercial T other <br /> installation will serve: Residen <br /> Humber of bedrooms_.�1 Water[able depth <br /> Number of living units. No,CarrtDartmanIo <br /> "racier Of aotl to a dapth of 0 foot:. Capacity��� <br /> SEPTIC TANK ❑ Typs1Mtg Method of Disposal �- <br /> PKG.TREATMENT PLT.Llpittance to nearest: Well Property Line�— <br /> �-- n-� Foundation�� <br /> Total length/size <br /> 0 No.6 Length 01 linrt Propet;V Line_ <br /> LEACHING LINE Well Foundation r <br /> FILTER BED 0 Distance to nearest: <br /> Number <br /> I 1 Deptfi --��'i:e -- Propel Line <br /> SEEPAGE PITS Foundation��- <br /> SUMPS Ll Distance to noarast: Well 1- 'talc laws, and . <br /> DISPOSAL PONDS ❑ <br /> 1 hereby eartity that!have prepared this application and that the work will ba ddne inacc°roance with San,foaquin county ordinances, <br /> wise and regulations o!the Sir,signature rtfies the foliow+ng:"I Certify that in the partarmanca Of the work 1Or which this permit is issued.I shell not <br /> Homs owner Of licensed agent's sip to persons subject to workman's comperes <br /> employ any paean in such manner as to bac�cnmencac9f�ie wo ta1°r�chtnis permitis issued.11 shall empnlYepe°r s hiring or sub•c°ntrecting signature <br /> conifies the following:"I certify that in itis pe <br /> Ilan laws of California," �.� 6 i <br /> The applicant must call for YI required ins na.Compete drawing on reverse side. �EaLO r T Date: t <br /> ' Title:, £ <br /> Signed ^'' i <br /> J it1 of rS n, �i v vA) FOR DEPARTMENT USE ONLY <br /> [ _ Date ' Area <br /> APPlicatien Aaceptad by Data <br /> Date Final Inspection by <br /> PLt or Grout Inspection by <br /> I Additional Commants: <br /> INTY h Applicsat Retsrn all copies to: SAN JOAQUIN COL <br /> AUSLI� HEALTH SERVICES <br /> D1Yt8I0H P£Ryl1T/SERYLCBS <br /> ENV H SAN ENVIRONMENTAL <br /> JOAHEALTH <br /> IP 0 BOX 2000, BIVCKTON, CA 135201 <br /> DATE PERMLT'NO. _ <br /> FEE AMO'.lNT OtlE AMOUNT REMiTTfD <br /> `�3H RECErV ED BY <br /> J <br /> \ <br /> WEENRUM vim <br />