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SAN JOAQU I N COUNT f I]UIIL I C HEALTII :;BIIV ICES
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> •145 N SAN .JOAQU I N, 1)11()Nl-; (209)-168-3420
<br /> P 57-�
<br /> t) BOX 2009 . STOCKTON, CA 95201
<br /> Pl;ItMI't ERI'IIIES 1 Yf:A1t FRQ3f DATE I��UF� r
<br /> — l,�rrmp lit,• :n ;'1I111r'att• I
<br /> App'Scatton le ceret•y Iwai- •. !ion *,AquIr. ccanty tar s T+r=" ..••r., wr.1 r :naew:: •• •• '•r••:r d••s rt:+d. ':h3a
<br /> appliratlon Sw awde in c�,L•Anc+ with Tan doaqutr -.r.•.r -. --• »»� surf atAt -•.rpu:•• arnn
<br /> t F+a+rlatt••na of Sa
<br /> oaquIn County Pub/lc health s-l-vLcea.
<br /> job Address - Lod t
<br /> Owrfw't teams Saul Fa$�Ld�a.__--__-- A,,-,•is 20326 F. Brandt Road Phphe - -----
<br /> Cont,ac,o,Purv_iance Dri 11ersAdd,est P-.0., Box 64 Linden 377923 887- 5-r,4-
<br /> TYPE-Or WELL oU�fP NEW WELL " V.1:L( PE 1r;•t.E:4'.' :'L>'AJC'ION ',tit of Service Y.11 Ll
<br /> �--- PUMP INSTALLATION SYSTI•! REPAIR 0714ER X�� afbnitcrir43 4e11 fl
<br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES ---- - OfSPODA, ;LD PROP UNE _
<br /> FOUNDATION AGRICULTURE WEI L__ OTHER WELL PITS:SUMPS _-
<br /> INTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTtnN SPECIF-CAT•O%S
<br /> nAlratrel- U Open Bottom C.Manteca DA of Wall f.clavafr,n _ l Za y_ Dia of Wen Cos,ng
<br /> XOwnestte Private �1 Gravel Pack C Traev tree of Caa•nq __ Specdn
<br /> eatos
<br /> P,**c .'Other t Delta Depth.,I lPnu, "Iva. _ - ._..- ivpe M G,cwt
<br /> I""t on __- Apf os Depth Eastern Surface Seat Installed by
<br /> Repan Work Done Type of Pump - H P r_-.- -- _ -- ._ -- State Work Duro _ ,-
<br /> Wee Destruction Well D,anetw _ o?a13ry{ Material • LLpth _
<br /> Depth Filler Material • D►p•.h �_ —1
<br /> TYPE OF SEPTIC WORK NEW f"STAT LATION � REPAIR cpprT104 [ASIPtIJTIO►. 101.,urtow srstarn pe•'v Invil J svwa•a ,
<br /> 4,a•lable w.trun"feel I rn
<br /> Installation wdl se,ve Residence__- Commercial Other -- -- N
<br /> Number of kv,ng units — Number of bedrooms
<br /> Ch tec"m of toll to a depth of]feel _ _ %Ater Is".*depth
<br /> SEPTIC TANK O TypeiMtIj _-_ Canarty ____-- - No Compwrrfants
<br /> PKG TREATMENT PLT Cl Method of O WQsar
<br /> Distance to newest Well -_ Fourda"n - �. P,O{enr I"
<br /> LEACHING LINE Ll No Al Length of Mel ____.- --- .-- _ Total 4np,n fl.te ____-.._______ -._•-__
<br /> FILTER BED CI Distance to newest. Wee- Foundation P,opw1v Lane
<br /> SEEPAGE PITS I I Depth -._.. __ S•» _ _-- -_- _._ Numow
<br /> SUMPS t' Distance to newest Wall _ Founds--on, --_-.- P,opwfv Lane---
<br /> DISPOSAL PONDS 1_l
<br /> 1 PetebY Certdy that I have prepared this Application and that tM wO k war be.f••ne In ICcnrAantw w,fh San Joaquin cour•ty ord•rances state laws. MA
<br /> rules end regutstions of IM San JoaquN\ Countr
<br /> Home owner or licensed"encs s,pnsture certifies the is3k0 ,ng "I certify that-tM pvwa-.lance of the wort fnr.which M,s pwrrrot,s issued. I shall nn,
<br /> en+Dfov err pafrspn rn such rttanne,as to Decone eub,ect fo workman's cvtwpensat,nn laws of Cat•fnrroa Cnnnactor a nwtng a wo crrntiAc ting spnatu,e
<br /> ceetrfea the foeowtng 'I eernfv thio,n the peAotmance of the work to,yrh.ch this W„^rt•s awed I shag emptor Parana subject to work nal is cornpenu
<br /> ren I�,Ira�L� fornix..1r
<br /> Thick\ y at c iM M M+apectgm
<br /> na Coptetw ,n
<br /> d,awp on rrawarso ft-ft-de•
<br /> TttN -_Lit tj'�l! tate
<br /> FOR DEPARTMENT USE ONLY 'f ^-TT
<br /> ADpbcatton Accepted njjr _ �►L _S �LL.la(d.'Yr►. Ula» --� 1r .y,3_-_ . A,” -V..1 jf ,
<br /> Pi,or Grout Inspacton by _ ___-- Date ... f her Inape:to.br _ ..__ Dee
<br /> /
<br /> A;•dNfO„N CWrw.en,. -y�llk4_J��!�- __�"/ � �yr_.__;. .,r_t..-��C �
<br /> 4ppl I-n, urlf1rr,
<br /> all r•r•ptow fn: �aon.f,.s u t'••unrr i•nhu• a..trn sr.rf .w •�., ( { ' I
<br /> 6nvir,arnral N.•alrh p••ra,lt »r.,.r•.
<br /> 146 N Gal. .',eq,rl n, 1• r• fr••• l•.. '+tkn, . •• ).•I
<br /> FEEAMOUNT BHf AMOUNr AEMtrt to s -T afrht:fD•v T BATE PI AkMt AO
<br /> INFO -_
<br /> far/ .s. �N a ��' /_7� _ ;1 ' S
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