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APPLICATION FOR PMWIT <br /> BATF JOA6 UIN E OUNTY PUBLIC HEALTH SRRVICBS /;Z,—NO�M <br /> SAFVIPONWMAL IEAI.TR DIVISION u <br /> 1801 S. HAZELTOH AVE., PHONE (2.09)4588-X3420 <br /> P 0 BOX 3009, MWITONr CA 95301 <br /> (Complete in Triplicate) <br /> i Anitettian is 11MIF W".tb SM J064MLS County tet a permit to pmvLF,.wt and/or Inotoll the vark btr*la dtaeribed. Thio Y <br /> I solicetiea le wde in compliance with am Joaquin.County Ordieaact go. 549 sad 1652 sed the IhWa and Rogulrtione 0f Sao <br /> It J*Wln tmnty Public health Rar►lcaa. <br /> f <br /> S, C'tv L."fitor s.QOi.6t tltsaJACr*d0 CALJrA AAdrese - <br /> ownw.NW4 ,S&t AdOtan _Adm - phone <br /> e <br /> Can <br /> tratftlr, SLA 1✓D � l�AD-- Adttnib, 7.w/. AD�q,GeF�.e�..�' - _--f.icense Ra. -Phone - z <br /> WPM VaU./PUMP: NEW WELL 0 WELL REPLACEMENT h DESTRUCTION 0 out of Mortice Well ' <br /> PUMP INSTALLAT*N 0 SYSTEM REPAIR 0 OTHER 0 IIoRiUo 1w Well cl <br /> DISTAWj TO NEAREST: SEPTIC TANtt 5EWER LINES DISPOSAL A.D.— PRW. LINE <br /> FOUNOAT*N ....�,..�.AGRICULTURE WELL OTHER WELL—ffM/SUMPS <br /> WtNDID use TYta¢OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 llwwtrw 0 Ogen E>mom a Manteca Date.of Won Eatav,tion Drs,of Wen Coskq <br /> tl 0~i6tPrivpts 0 terww Pw* a Tracy Tose of Cuing_ SPRof mwm <br /> 1-1 pitrc 11 COM it Oona Depth of Grout 3" TWO of <br /> c Ire gation . .Alipfas.Deplft I 1 tastafrt Surface Seat tnatallsd by <br /> ft`*po Worn DOM U TWW of Pump N.P. Soar Werk tone <br /> trwrerf'Oeooit last 0 Won Ditttnom aftliet lfatwl"a Dapt:h <br /> br�tA Pillar 1Ytbrlal 0 Depth � s <br /> TYPE OF 99PTIC WORK: NEW INSTALLATION I I REPAIRIAODITIO;OC DESTRUCTION I I Wo sapnc syetern it PAWL lawn to � i# <br /> sv wom n <br /> W4%b*m VA bow.: Aoa r_,,.,,,. Cesar tw .. O"w <br /> ll+ Rat of E,"unite:__ r,Iwrtb.r 0 0erl+>Joene <br /> Chatecsot of V A to 6 depth of 3 faro' - Watat tabb depth <br /> SEPTIC TANK 0 TOO/Mfg f>r Capacitlr ii:n Na,cwmwbmm Z. <br /> PKG.TREATMENT PLT.0 r Mrftd at 01e0a541 <br /> Ditdrm 10 as~. WO fOd t pgttwtation . 10' - PtapeM Lin. L&50_ __ 9 <br /> LEACHING UWE No,t Longo%of Mn Toed NMI: <br /> r fILTE11 1510 0 Dhwtoa to neatest: Wed ria Founeatan ?tea' Pmpom lin. <br /> i <br /> SEEPAOE PITS t�DeaPh lr Sian__" �' --.., thteteber t <br /> StMPS LI Diatanaa io n.tttat: Wen t Facndation _ Progorty lin._/arm,�- ; <br /> 35tSPOS&PONDS 0 <br /> j I tw:e Dy cs:n(v that I have preparW thio app5witto and rhes tale work vrAt be dw*in accmdance with San Jovq&M county orditwowe,seas laws,and <br /> rul4avps tmioft of Ih6 San JoKum Cawtr <br /> Hv-`*=jvvts.s'w 1iNJ"d cont-$e>gn6' m owtif a IN f uowvE:"1 cwWy Chet io the ps0om nw of the*OM to#whkh this pMmit is 4%ted.1"0 not <br /> fwtplor wy reftan in sw:"ntennat as to hwAm amt wt to werkmares compansafi)n taws of California."Contractes i»ring or vjb-cwfr.Ct0V signatute <br /> s;.rtkrios the 1060wing:"I Cattlfy gest in the pwo""we of the work for which Iiia p"i is isawad.1 she emptoy owsons oubist:t:o woAman's Comw". <br /> ttoo w"of cwomw," <br /> The&Dpkmw Awa cs%far so evwm, Inspgctiofat. a Orem"an moons sih. <br /> siy,ed x ✓Jf'..�.��! /1J�-Y Tttlr: Date: —5? <br /> DIPARTMENT UBE ONLY <br /> iJ~ / <br /> I AppNiewtim Acc*p ea br .F.I.0oor Dlsa Aroe <br /> Pit a G4 out tnapsctlam try Dna fine!Iropactiotr by Oaa <br /> $ddttt0net Coatngime: <br /> i App1jesat d Return all Capita tot Sea JOequfa County Public Health <br /> Sarvicaa. laoviraoaaatal Realtb Permit/Services <br /> 1501 S. ft"ltm Are.. P 0 bat 2009. SU*ktoa. CA 95201 <br /> f nt10 AMOUNT DO AMOUW AIMITTI6 CASH AEC"D Ay DATA pEpM1?Lh0. <br /> tM 1)aA Mv. <br /> fel 1�•7a " <br /> �( tt <br /> 1 5 <br />